Shasta County Grand Jury
2003-2004
Findings & Recommendations
8 findings
F1:
The Ralph M. Brown Act is California’s open meeting law for local governmental bodies. The Act is found in sections 54950, et seq., of the Government Code and requires, in general terms, that governing bodies of local public entities, including joint powers agencies, must maximize public access to and involvement in the governing bodies’ meetings by posting their agendas and holding their meetings in locations freely accessible to the public. The Brown Act further prohibits the governing body from placing conditions on attendance at the board’s meetings, including a prohibition against requiring attendees to register. The Grand Jury attended the January 12, 2004 meeting of the SHASCOM Board of Directors. This meeting was held in SHASCOM’s facility, which is surrounded by gated security fencing. In order to enter the facility, the public must request permission to enter the locked parking lot by speaker box. Access to the building itself is gained by requesting the door be unlocked. In order to attend the meeting, a visitor is required to sign a visitor’s log. The SHASCOM Board of Director’s posts its agendas inside its facility, a location that is not freely accessible to the general public. As part of its investigation, the Grand Jury confirmed by interviews that since 2002, SHASCOM’s Board of Directors meetings have been held in the secured building, that their agendas were posted inside the building and that persons were required to sign a visitor’s log. These practices are still on going.
F2:
SHASCOM has implemented Reverse 911 as recommended by the 2000/2001 Grand Jury. Reverse 911 allows SHASCOM to notify citizens by telephone in a specific geographic area of an existing or impending emergency.
F3:
There are only 19 active dispatchers out of the 34 allocated positions. The reasons for this shortage are an inability to obtain qualified trainees, stress, mandatory overtime, on-call requirements and salaries that are not high enough to attract lateral transfers from other 911 dispatch centers.
F4:
Mandatory overtime is a condition of employment.
F5:
SHASCOM has a budget surplus of approximately $280,000 for the 2003/2004 fiscal year and an estimated $80,000 surplus for the 2004/2005 fiscal year. These surpluses are scheduled to be refunded to the user agencies at the end of each fiscal year.
F6:
SHASCOM uses five radio channels: Redding Police, Shasta County Sheriff, Services Channel, Fire and Emergency Medical Services. All dispatchers are required to be proficient on either the Redding Police or Shasta County Sheriff Office channel, plus the Services Channel, the Fire Channel and the Emergency Medical Services Channel. Six dispatchers are cross-trained on both RPD and SCSO Channels and receive a 5 % pay increase for being proficient on both.
F7:
SHASCOM Board of Directors has four voting members. This means there is no tie- breaking vote.
F8:
SHASCOM offers a $500 hiring bonus to potential lateral transfers.
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Findings & Recommendations
9 findings
F1:
Before the March 2, 2004 election, there are no school bond assessments in the district.
F2:
In November 2002, state voters passed Proposition 47, the State Schools Facility Funding Act. GESD received $4.6 million funding approval in December 2002, which was insufficient to complete the project, which consists of permanent classrooms and new athletic field facilities. The GESD Board determined they had three options: • Return the funding to the state. • Spend an estimated $250,000 for an architectural redesign to downsize the project. • Propose changes to the project to reduce its cost. The GESD Board held several meetings to discuss the options, surveyed Grant’s parent community and gathered input from school employees. Overwhelmingly, it was the opinion of the GESD Board of Trustees, parent community and school employees not to send these funds back or to redraw and downsize the plans but to construct what had been drawn with the understanding that it would be likely that it would take a bond measure to finish the job. The GESD published a request for proposals in December 2002 which included four construction alternatives to be bid in case the lowest bid exceeded the $4.6 million. Mandated oversight, inspections, engineering, architect, excavation costs and a percentage for reserves reduced available construction funding to $3.9 million. The low contractor bid included proposed changes that if accepted would delete $822,000 from the original bid and reduce it to the $3.9 million available. The GESD Board decided to accept the bid with the proposed changes and proceed with construction.
F3:
The Grand Jury did not find that the GESD Board violated any laws or regulations in its decisions concerning construction of the Junior High School.
F4:
Fundraisers are held in the GESD throughout the year for various school projects: • The Parent Teacher Organization raises funds that are deposited with the Centerville Education Foundation for teacher mini-grants. • Students for Classrooms Funds hold a Jog-A-Thon. • Sport Boosters Club for sports related activities • Music Boosters Club for music related activities • Sod Busters, a one-time committee, was established by volunteers to raise money for athletic field construction to be done by volunteers. The committee raised $40,000. These funds were insufficient to complete the project. The school administration determined that the project was not feasible for volunteers to undertake the work. The money was placed in trust with the Centerville Education Foundation to be used for the same purpose when additional funding was available.
F5:
The GESD borrowed $100,000 from its school bus replacement fund to complete Junior High School construction to the point where it could obtain a certificate of completion. This certificate is required to use the facilities.
F6:
If the GESD proposed and passed a construction bond measure prior to completion of the current project, the State School Construction Office would have required that money to be returned to the state as matching funds. The GESD Board decided to wait until a notice of completion was obtained before submitting the bond proposal to voters.
F7:
The Grand Jury found the Junior High School classrooms are finished and usable, including the science, math and computer labs. The unfinished facilities are the gymnasium, performing arts stage, shower and locker rooms and athletic fields. The home economics room, staff lounge and library are finished except for furnishings and are partially usable.
F8:
The GESD placed a bond measure for $1.7 million on the March 2004 ballot to obtain the revenue required to complete the improvements needed to utilize all the new facilities, as well as $300,000 for bond costs, interest and to pay back the bus replacement fund.
F9:
On March 2, 2004 the district voters passed a $1.7 million bond to fund completion of the GESD Junior High School.
Additional Recommendations
2
Not linked to specific findings.
R1:
None RESPONSE REQUIRED: None MANAGEMENT AUDIT OF THE SHASTA COUNTY AUDITOR-CONTROLLER’S OFFICE REASON FOR INQUIRY: Shasta County Auditor-Controller California Penal Code Section 925 Shasta County Courthouse, Room 104 authorizes the Grand Jury to investigate 1500 Court St Redding, CA 96001 and report on operations, accounts, and records (530) 225-5771 of the officers, departments, or functions of the county. California Penal Code Section 928 authorizes the Grand Jury to investigate and report upon the needs of all county officers in the county, including the abolition or creation of offices and the method or system of performing the duties thereof. BACKGROUND: The Shasta County Auditor-Controller (Auditor-Controller) is the chief accounting officer of the county. The Auditor-Controller is entrusted by the citizens of this county to prescribe and exercise general supervision over the accounting process and the method of keeping the accounts of all county offices, departments and institutions under the control of the Shasta County Board of Supervisors (the Board) and of all districts whose funds are kept in the county treasury. The Auditor-Controller, an elected official, is ultimately answerable to the voters. However, the Board has authority to supervise the official conduct of county officers such as the Auditor-Controller. In response to the 2001-2002 Grand Jury recommendation, the Board authorized a qualified outside contract auditor to conduct a management audit of the Auditor- Controller’s Office. The Board initiated the recommended audit process in the year 2003. METHOD OF INQUIRY: The Grand Jury interviewed: • Two members of the Shasta County Board of Supervisors • The Shasta County Administrative Officer The Grand Jury met with: • The Auditor-Controller • The Assistant Auditor-Controller • The County Budget Officer The Grand Jury reviewed: • The Limited Scope Management Audit of County of Shasta Office of the Auditor-Controller, February 13, 2004 • The Review of Limited Scope Management Audit of County of Shasta Office of the Auditor-Controller, March 23, 2004 FINDINGS: A. The recommendations contained in the Limited Scope Management Audit of County of Shasta Office of the Auditor-Controller, February 13, 2004, prepared and presented by Harvey M. Rose Accountancy Corporation, are as follows: 1. Financial Oversight. The Auditor-Controller should: 1.1. Conduct a survey of County departments to assess their financial management needs, and enhance the Auditor-Controller’s training programs and Accounting Procedures Manual to better meet the needs of County departments. 1.2. Prepare written policies and procedures for the Auditor- Controller’s Office regarding oversight of the County-wide fee setting process, including assistance to departments in relation to the establishment, review and updating of rates and charges. 1.3. Assess and review training provided to accounts Payable staff to increase consistency in claims processing. 1.4. Increase analytical support provided by the Auditor-Controller’s Office to the County departments and to the Board of Supervisors. 2. The Purchasing and Accounts Payable Processes. The Auditor-Controller should: 2.1 Tighten and expand existing internal controls over the Accounts Payable process, including ensuring that: (a) Supporting documentation is submitted with all claims; (b) A County employee cannot provide more than one authorizing signature on each purchasing or payment document; (c) The same person in the Auditor-Controller’s Office does not authorize the claim as a department designee and as a Deputy Auditor-Controller; and (d) Explanations on the claim form are sufficient for a third party to ascertain the nature of the expenditure. 2.2 Evaluate, in coordination with the Purchasing Agent, the purchase order process to determine why purchase orders are being issued after invoice dates, develop an action plan to rectify the situation, and report back to the Board of Supervisors on that plan by June 30, 2004. 2.3 Develop procedures, in coordination with Purchasing Agent, to identify and resolve instances of non-compliance with purchasing policies and procedures, including enforcement provisions, and submit such procedures to the Board of Supervisors for review by June 30, 2004. 2.4 Enforce purchasing policies and procedures through the procedures developed pursuant to Recommendation 2.3 above. 2.5 Work with the Purchasing Agent to develop a procedural or system solution to the duplicate review of purchase orders by the Auditor-Controller’s Office and report back to the Board of Supervisors of that solution by June 30, 2004. 2.6 Survey departments on issue areas, develop and implement an action plan for addressing these areas, update policies and procedures and internal training manuals, and report back to the Board of Supervisors on the survey findings and the Auditor- Controller’s Office action plan by June 30, 2004. 2.7 Train staff in Accounts Payable to process all types of claims and assign work based on departments rather than claim type so that departments and Auditor-Controller staff can develop a more constant and productive relationship. 3. Board Claims. The Board of Supervisors should: 3.1 Eliminate use of the Board Claims listing and delegate authority to pay all normal and customary claims to the Auditor- Controller. 3.2 Delegate appropriate staff to clearly define exceptions to the normal and customary criteria and to develop written policies for approval or review of these exceptions by the Board. The Controller should: 3.3 a) Analyze recent Board Claims to identify areas of non- compliance with the County’s purchasing policies and procedures or sound business practices, b) Work with the Purchasing Agent to develop procedures to enforce compliance with the County’s purchasing policies and procedures, and c) Report back to the Board of Supervisors on those procedures by June 30, 2004. 3.4 Refocus the attention of Accounts Payable staff on enforcing the County’s purchasing policies and procedures. 4. Cost Allocation Plan. The Auditor-Controller should: 4.1 Work with the County Administrator’s Office to identify possible midyear budget reductions, resulting in actual FY 2003-2004 costs that are less than estimated FY 2003-2004 costs included in the cost allocation plan; work with County departments to reduce remaining quarterly reimbursement claims for the remaining quarters of FY 2003-2004, as necessary; and report adjustments to the Board of Supervisors. 4.2 Report to the Board of Supervisors the status of implementing systems to increase County Departments’ direct billing of central support services, the total amount of direct billing of support services for the prior fiscal year, and the anticipated effect on the estimated cost allocation plan, as part of the annual budget review. 4.3 Convert to the single cost allocation plan in FY 2005-2006 and report to the Board of Supervisors prior to December 31, 2004, on the conversion to the single cost allocation plan. 4.4 Reassign responsibility for developing the county-wide cost allocation plan to staff assigned to the Financial Reporting and Audit Division. 5. Employee Retention. The Auditor-Controller should: 5.1 Develop a training program and protocol, in conjunction with Human Resources, for working with new employees to ensure that they have the greatest probability of success and report back to the Board of Supervisors on that program and protocol by June 30, 2004. 5.2 Develop biweekly training checklists that detail new employees’ areas of competency, areas that have improved, and areas that continue to need improvement. 5.3 Institute quarterly department-wide staff meetings that include discussion between employees and management regarding the Auditor-Controller’s Office policies and practices. 5.4 Re-institute the pilot program for alternative work schedules, including working with employees regarding coverage problems, and differences between divisions on the application of alternative work schedules. 5.5 Develop and communicate policies regarding incremental leave without pay, reduced workweek, and job sharing. 5.6 Along with the Assistant Auditor-Controller and all management and supervisory staff, take a training class on the principles of good management and supervision by June 30, 2004. The Human Resources Department should: 5.7 Develop a training program and protocol, in conjunction with the Auditor-Controller’s Office, for working with new employees to ensure that they have the greatest probability of success and report back to the Board of Supervisors on that program and protocol by June 30, 2004. 5.8 Conduct a compensation and classification study for all managerial and staff positions in the Auditor-Controller’s Office and report back to the Board of Supervisors by June 30, 2004 with recommendations. B. In the Review of Limited Scope Management Audit of County of Shasta Office of the Auditor-Controller prepared by the Auditor-Controller, Assistant-Auditor, and the County Budget Officer, the recommendations as presented in the audit were classified into three categories: 1. Recommendations supported by County Administration are: • Enhance Auditor-Controller (A/C) training programs and Accounting Procedures Manual to better meet the needs of County departments. • Expand existing internal controls over the Accounts Payable process to ensure that explanations, supporting documentation, authorizations and purchasing policies and procedures are understood and complied with. • Board Authorization to eliminate the Board Claims listing for customary claims to the A/C and develop written policies and procedures for review and approval of exceptions. • Work with the County Administrative Office (CAO) and County General Fund departments to identify possible midyear spending reductions/increases and present adjustments to the Board for approval. • Improve employee retention through training and support of new employees, increase communication between employees and management, establishing a more professional work environment and implementing more flexible working conditions. 2. Recommendations that may have merit, but are too costly to adopt: • Convert to a single cost allocation plan and reassign responsibility for developing the countywide cost allocation plan to the Financial Reporting and Audit Division. 3. Recommendations that are not applicable to Shasta County: • Conduct a compensation and classification study for all A/C managerial staff positions. • By policy, Shasta County should “expand the current role of the Auditor- Controller to serve as an independent chief financial officer, including providing independent budget projections to the Board of Supervisors.” • Prepare written policies and procedures regarding oversight of the County- wide fee setting process. C. The Grand Jury has determined that the recommendations set forth in Finding B1, above, adequately address the findings made by the Harvey M. Rose Accountancy Corporation in its management audit of the Auditor-Controller’s Office.
R2:
The Auditor-Controller should place into action the recommendations listed in Finding B.1. The Auditor-Controller should report back to the Board of Supervisors by December 1, 2004, that these recommendations have been implemented. RESPONSES REQUIRED: The Shasta County Auditor-Controller The Shasta County Board of Supervisors
Findings & Recommendations
7 findings
F1:
The facilities include: • One, two story dormitory • Kitchen and dining building • Laundry building • Administration building • Guesthouse • Equipment storage building • Garage and Vehicle maintenance building • Inmate hobby shop
F2:
The grounds and buildings were in clean condition and well maintained.
F3:
Inmates on the fire crews receive extensive training (40 to 60 hours) at the California Correctional Center in Susanville before they are transferred to the camp. Upon release, this training aids the inmate in finding a professional fire-fighting job. The Sugar Pine Conservation Camp offers a program to obtain a General Education Diploma. Alcoholics Anonymous and Narcotics Anonymous meetings, Bible studies and hobby craft classes are available. Additional instructional training in fire fighting techniques and physical conditioning are also provided at the camp.
F4:
Visitations and phone calls are allowed and monitored. For those who qualify, weekend visitation is available at the guesthouse.
F5:
Immediate medical care is provided at one of the local hospitals.
F6:
The CDF/CDC Conservation Camp Management Survey represents a thorough inspection of all facets of camp operations and safety issues. The facility was in full compliance with the survey.
F7:
The Work Hours Report for 2003 lists a total of 96,510 project hours and 7,813 fire hours contributed by the inmates of Sugar Pine Conservation Camp. The CDF publication, “Conservation Camp Program” highlights the contributions by the California Conservation Program fire crews.
Additional Recommendations
14
Not linked to specific findings.
R1:
The City Council should not derail well designed Infill and Planned Developments. Response: Concur, if they meet the General Plan and other development policies as determined by the public’s elected representatives who are selected to make these decisions. The Grand Jury’s finding on this matter (No. 6) has substantial factual errors. The City Council determined that the project was not consistent with the General Plan. The design of the project contained aspects that did not comply with the General Plan policy. GJ Reply to the Response: The Grand Jury finds the City Council’s response unacceptable. The Grand Jury determined that the project was consistent with the General Plan. Furthermore, if “…the project was not consistent with the General Plan,” as stated above, then it should not have been approved by the Planning Department in the first place.
R2:
The Planning Department should attempt to expedite the permit approval process. The City’s Ombudsman report on recommended process changes should continue to be implemented. Response: Grand Jury Finding No. 9 states that “the City’s Ombudsman Report on Recommended Process Changes was presented to the City Council for consideration on October 25, 2004. …Some of these recommendations are being implemented by the City’s Development Services Department.” In fact, all of these measures are being implemented with the exception of the permit tracking system. The tracking system is extremely expensive, which is why it has taken longer than the other points mentioned in the Grand Jury’s findings. However, the City Council will be discussing this issue as the City looks at planning and engineering fee increases in the next few months. GJ Reply to the Response: The Grand Jury finds the response acceptable and looks forward to the implementation of the permit tracking system.
R3:
Political influence should not override sound planning decisions. Response: Concur. Grand Jury Finding No. 8 states that, “strong political influence was exerted on the Planning Commission and City Council to disapprove this project.” This is obviously a statement of opinion. It would be equally valid to say that strong political pressure was exerted on the Planning Commission and City Council to approve the 2 project. Concerns for and against projects will very likely continue as the City entertains more infill projects. GJ Reply to the Response: The Grand Jury finds the response acceptable. However, it remains our “opinion” that the front-row presence of McConnell Foundation executives at the City Council meeting regarding opposition to this project represented undue “strong political influence” against the project’s approval. Report No. 2: Haste Makes Waste In a lengthy report, the 2004/2005 Grand Jury investigated the closure of the Shasta County Psychiatric Hospital Facility (PHF) and its impact on inpatient care of the acutely mentally ill. The overall operation of the Shasta County Mental Health Department (SCMH) was also investigated. The required response from the Shasta County Board of Supervisors (BOS) was sent to the presiding judge of the superior court on September 27, 2005. The Director of SCMH was also invited to respond to certain recommendations; the response was received on August 29, 2005.
R4:
The Shasta County BOS should consider privatizing, in part or in total, the delivery of mental health services to the citizens of the county. With proper oversight, this would offer a more efficient overall operation. Assurances that all patients requiring treatment actually receive treatment would be necessary. The Grand Jury feels an extensive and well-planned transition program, with input from the general public and all providers of mental healthcare delivery, must precede any transfer from public to private operation. Response from the BOS: Currently 54 percent of the SCMH budget is devoted to contract services, and this has consistently increased over the past 2-3 fiscal years. As a result, SCMH is more than half “privatized.” With each contract for services entered into by the BOS, SCMH must assure that services are delivered in accordance with State Department of Mental Health requirements, which govern target population, service delivery, and the receipt of State and federal funds. SCMH provides mental health services to the residents of Shasta County in compliance with three State Department of Mental Health contracts. These contracts include very specific terms and conditions and are renewed annually with the approval of the BOS. (A one-page description of the contracts accompanied the response). The Grand Jury notes in its findings a number of perceptions regarding the role of SCMH in the delivery and authorization of inpatient mental health services that are not consistent with this contract and SCMH’s practice. The first and most important misperception is related to access to psychiatric hospitalization for all Medi-Cal eligible Shasta county residents. There are no pre-authorization requirements for emergency admissions to psychiatric inpatient hospitals for Shasta County Medi-Cal beneficiaries. SCMH provides post-admission review of written Treatment Authorization Requests submitted by hospitals as required by the State prior to payment by EDS (Electronic Data Systems). Since SCMH is no longer a provider of psychiatric hospital services, independent practitioners affiliated with the private treating facilities now make the determination of the patient’s admission and continued stay. GJ Reply to the Response: The Grand Jury disagrees with the response. The intent of the recommendation was to consider privatizing the entire mental health delivery system in Shasta County, including its administration. The privatization discussed by the BOS was, in part, necessitated by the closure of the PHF; patients who require hospitalization for acute mental illness now need to be hospitalized out-of- county (i.e., “privatized”). SCMH does serve as the managed care provider and pre-authorizer for Medi-Cal beneficiaries in Shasta County. This was confirmed by the SCMH Director (on two occasions), Deputy Director, and by multiple psychiatrists during the investigation; the Director of the NVMA concurred during a public forum held by the BOS in April 2005.
R5:
The Grand Jury recommends the SCMH Director improve lines of communication to ensure that SCMH policies affecting the medical community and other public agencies are uniform and consistent. We encourage SCMH to continue to improve access to its crisis intervention teams to reduce emergency room transfer delays. Moreover, to improve the continuity of patient care, we suggest that SCMH expedite the transfer of medical information (history, diagnosis and prescriptions) along with patients requiring out-of-county care. Conversely, SCMH should demand that discharge summaries accompany its patients returning from out-of-county facilities. Additionally, 6 the Grand Jury discourages the indiscriminate delegation of 5150 authority by the SCMH Director. Response from the SCMH Director: SCMH concurs with the recommendation regarding communication with the medical community and out of county facilities. SCMH will promote collaborative efforts with the NVMA to provide education and training for area physicians regarding the treatment of psychiatric illness. As stated in Response No. 3, another solution to the local emergency department congestion and transfer time delays is the implementation of a coordinated case management system that will provide wraparound medical and behavioral healthcare, and psychosocial supports to a population identified as frequent utilizers of the Mental Health emergency response system. SCMH, in collaboration with North State counties, looks forward to the opening of the North Valley Behavioral Health and Sequoia Psychiatric Center PHF in Yuba City, both of which will exclusively treat our patients. This will greatly enhance the continuity of care and communication of critical patient care issues on admission and discharge for Shasta County patients. GJ Reply to the Response: The Grand Jury generally agrees with the response, however, the indiscriminate delegation of 5150 authority was not addressed.
R6:
SCMH should establish written cost-sharing policies with the County Jail, Juvenile Hall, Probation department and other agencies for inpatient care and transportation of their mentally impaired inmates or clients. SCMH should improve its service to county agencies affected by the PHF closure, e.g. attend to inmates at the Main Jail and Juvenile Hall. Response from the SCMH Director: The Shasta County Sheriff’s Department and Probation Department maintain a contract with Prison Health Services for the provision of health and mental health services in the jail and juvenile hall. This contract is comprehensive in scope and specifies the responsibility of the provider in the provision of all planned and urgent medical services, including psychiatry. The contract includes the responsibility of the provider for reimbursement of hospital services for inmates and wards in custody, but excludes the contact provider from responsibility for reimbursement for psychiatric hospitalization. As a result, there is a serious gap in coverage for jail inmates in custody and juvenile wards in custody. SCMH works cooperatively with jail and juvenile hall staff to address this gap on a case-by-case basis, following written protocols that were developed collaboratively between the Sheriff’s Department, Probation Department, and Mental Health. SCMH also provides the services of a psychologist in juvenile hall and SHIFT (Shasta Housing Intervention For Transition) Program services in the jail to assist Prison Health Services and the courts with inmate/ward mental health issues. GJ Reply to the Response: The above response is inadequate. It does not address transportation protocols and/or cost sharing between SCMH and incarceration facilities since the closure of the PHF. The problem of court ordered on-site psychiatric evaluations is also not addressed. Jail representatives were unable to produce written protocols for inmate evaluation and treatment.
R7:
The BOS and SCMH should closely monitor the costs (including all transportation costs) of out-of-county inpatient care. The Grand Jury offers the following options for reestablishing inpatient psychiatric services for which the County still holds State licensure: iReopen the 15-bed PHF at the previous site on Breslauer Way by deleting its Medicare designation and adopting strict admission criteria for adult inpatients. This would reduce the average daily cost of care by 50 percent (to $2 million per year) and also minimize patient safety issues. Medicare inpatients requiring hospitalization would be cared for at other facilities. iOpen a 15-bed basic PHF on Breslauer way as a combined adult/child inpatient facility by designating 10 beds for adults and five for children. iOpen a 15-bed basic PHF on Breslauer as the only north state child inpatient facility. Costs would be more manageable and there is a very low risk of associated physical co- morbidity in this age group. The BOS should obtain sufficient information to determine whether or not to renew the SCMH $1.3 million yearly contract for the Elpida Crisis Residential Center. Any option to reopen a PHF would necessitate either closing or relocating this center. The Grand jury recommends closure. In that event, inpatient psychiatric services could be funded using current SCMH revenues generated by increasing efficiency, reducing out-of-county inpatient care, substituting primary care practitioners for some psychiatrists and eliminating costly Medicare staffing. Moreover, additional funding may become available beginning in 2005/2006 through the Mental Health Services Act. The Grand Jury believes that County residents could, and should, have local access to both inpatient and outpatient mental health services. Inpatient child psychiatric services have been identified as woefully inadequate for decades and the Grand Jury invites Shasta County to take the initiative and establish a child/adolescent inpatient facility. A north state regional, multi-county proposal for Mental Health Services Act funds (perhaps orchestrated by the SCMH Director) could establish a geographically centered, acute care facility for children with mental impairment. Benefits of such a facility to the overall mental health of children include earlier recognition and treatment of impairment and an improved continuity of care. Enhanced case management, better social rehabilitative services, access to intensive family psychotherapy and recruitment of more child psychiatrists could result from a successful program. This is an opportune time for Shasta County to address the psychiatric needs of north state children. Response from the BOS: SCMH has submitted the planned budget to the Shasta County Administrative Office including projected expenditures and revenues for fiscal year 2005/2006. In this budget, the SCMH department does not recommend that it operate a staff a psychiatric health facility during fiscal year 2005/2006. The BOS concurs that an involuntary mental health acute care inpatient unit is needed in Shasta County but realizes that patient safety is of the utmost importance. In an effort to meet the medical needs of all patients, the delivery of mental health treatment services (involuntary or voluntary) should be integrated with emergency and primary health care. The County PHF was not licensed to provide emergency medical or primary health care services, therefore, reopening the facility is not viable. SCMH, in collaboration with the Shasta County Administrative Office and the North Valley Medical Association (NVMA), has facilitated contacts between interested providers of inpatient behavioral health services and the administrators of the local general hospitals. The goal of this collaboration is to integrate acute care psychiatry into mainstream primary health care so that those suffering from mental illness have the opportunity to receive treatment for all of their medical needs in an environment where they are not stigmatized or isolated form medical care. The BOS agrees that a regional approach to specialty psychiatric care is viable for target populations. An example of the potential in this area is the soon to open North Valley Behavioral and Sequoia Psychiatric Center PHF. SCMH has taken a strong leadership role in this 4-year effort and the SCMH Director sits on the steering committee that has been responsible for the planning and implementation of these facilities. Specifically regarding the viability of a regional facility for children, SCMH has promoted three regional options. The first option was the establishment of a regional locked community treatment facility, which was not supported at a regional level. The second option was the dedication of one of the new regional psychiatric facilities to children, which was also not regionally supported. The third option is the establishment of a regional interagency crisis assessment center for children. This option may be considered as a priority focus under the Mental Health Services Act. GJ Reply to the Response: The Grand Jury disagrees with the response. Adequate revenue exists for the reestablishment of a local, scaled-down (i.e., non-Medicare) PHF. Strict admission criteria would greatly reduce patient safety issues. The BOS talks of integrated care, but the SCMH Director’s responses to recommendations 2, 3 and 5 above, do little to promote integration with primary health care. The BOS response claims the County PHF is not licensed for emergency medical or primary health care and therefore, reopening it is not a viable option. The Grand Jury notes that while none of the State PHFs are licensed for emergency medical or primary health care services, they continue to provide acute psychiatric inpatient care. The Grand Jury further notes that the North Valley Behavioral and Sequoia Psychiatric Center, to which Shasta County sends inpatients for treatment, is not a full-service hospital providing integrated health care. Moreover, the BOS response does not address the recommended closure of the Elpida Crisis Center. The Grand Jury suggests that the BOS need only look as far as Butte County to consider a functioning non-Medicare designated PHF. The Butte County PHF exists because of support by both the general public and the Butte County Mental Health Director. The integration with mainstream medical care for their patients with co-morbidities is easily obtained because of a positive relationship with the medical community of that County.
R8:
Other inpatient psychiatric services could include: iThe reopening of inpatient services for Medicare patients at a local rehabilitation facility. iA truly collaborative effort between SCMH and the local medical community too begin laying the groundwork for an inpatient psychiatric unit in one of the local full-service hospitals. Response from the BOS: The Shasta County BOS concurs with the recommendation that a local inpatient facility should be pursued. This facility should have the capacity to treat patients flexibly, which is best done in a licensed general hospital. SCMH, in conjunction with the Shasta County Administrative Office, has facilitated contracts with three corporations that are providers of behavioral health services that would like to develop a local inpatient facility. At a recent presentation, one provider made it clear that the provision of behavioral health services in a licensed general hospital with more than 100 beds is financially viable and of economic benefit to the hospital. NVMA representatives have made it contact with this provider and will facilitate meetings in an effort to promote the proposal, gain support from local hospitals, and encourage community involvement in this potential opportunity. GJ Reply to the Response: The Grand Jury accepts the response and awaits the outcome of this potential effort. The SCMH department is working with the NVMA to facilitate contacts between interested psychiatric providers and local hospitals. The Grand Jury applauds this portion of the response, but as noted in our report, the establishment of a psychiatric unit in a local full-service hospital is a three-year process.
R10:
The Grand Jury suggests that the BOS pay a site visit to the County-contracted Elpida Crisis Residential Center and closely evaluate the benefits of the contract’s automatic renewal after fiscal year 2004/2005. Should Elpida remain open, the Grand Jury also recommends adoption of a formal lease between the County and Elpida’s private sponsor and establishment of an Elpida Policies and Procedures Manual. Response from the BOS: Representatives from the BOS, County Administrative Office, and Mental Health Advisory Board participated in a tour of the Elpida Crisis Residential Center on September 7, 2005, as recommended by the Grand jury. The Elpida crisis residential Center maintains a policy and procedures manual that addresses the areas required by State regulation. GJ Reply to the Response: The Grand Jury finds the response inadequate. Only two Supervisors participated in the Elpida tour and no evaluation of the benefit of extending the contract was made. The response did not address a lease between the County and Elpida’s private sponsor. The Grand Jury is still awaiting receipt of the Policy and Procedures Manual from Elpida.
R11:
The Grand Jury recommends the County BOS and SCMH consider both financial and staffing support of a proposed County Detoxification Center. This center would afford opportunity for an improved collaboration between SCMH and both the local medical community and city governments. Establishment of a detoxification center would reduce the congestion in local hospital emergency rooms. Mental Health Services Act (Proposition 63) funding could be an additional source of financial support. Response from the BOS: The BOS, SCMH, and the Shasta County Alcohol and Drug Programs (SCADP) are in complete support of expanding the social model detoxification program in Shasta County. This is consistent with the “Community Action Plan” developed by representatives of Mercy Medical Center, Shasta Regional Medical Center, Shasta Community Health Center, the Good News Rescue Mission, SCMH, and the SCADP. A memorandum of understanding (MOU) has been developed by SCADP and circulated to the participants and other recommended collaborative partners. To date, only the City of Shasta Lake and the Shasta County Administrative Office have responded with support. The role of the Mental Health Services Act (Proposition 63) funding in this service expansion will be determined once the State Department of Mental Health guidelines for application for funding have been finalized and distributed. Additionally, the input received from stakeholders at more than 30 State required focus groups, conducted by SCMH, must be considered when prioritizing areas of need for mental health services expansion. This process targeted for completion in October to allow for a timely submission to the State Department of Mental Health. GJ Reply to the Response: The Grand Jury is satisfied with the response. We are also discouraged that only two collaborators have committed financially to a project that received unanimous support from all interviewees.
R12:
The Grand Jury recommends that County and City Government guarantee public safety at all times by ensuring law enforcement personnel attend to 11 5150-designated patients while they are treated in, and until they are transferred from, local “unlocked” emergency rooms. Response from the BOS: The process for transfer of law enforcement 5150 detentions is governed by an interagency agreement developed by local law enforcement agencies in collaboration with representatives of SCMH, Shasta regional Medical Center, Mercy Medical Center, and Mayers Memorial Hospital District. Less than half of the calls to the emergency departments are the result of this process. More than half of the calls for SCMH crisis response are for patients who have presented to the emergency departments without law enforcement involvement. Thus, law enforcement personnel are not present in these cases while the emergency department examines the patient to determine if an emergency medical condition exists consistent with the federal requirements under the Emergency Medical Treatment and Labor Act. In these cases, SCMH determines the legal status of the patient if the emergency department physician decides that transfer or discharge to a specialty psychiatric facility is necessary. Response from the City of Redding: The Grand Jury recommendation requires further analysis. The Police Chief cannot guarantee that law enforcement personnel attend to 5150-designated patients while they are “treated in, and until they are transferred from, local unlocked emergency rooms.” It would mean that police officers would need to be diverted from our neighborhoods and businesses to attend to individuals who should be at a detoxification center or at a mental health facility for as much as 24 to 30 hours. Currently, police officers remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to themselves or anyone else. Since the closure of the County PHF, police time necessary to handle these calls has already increased 66%. Remaining at the hospital to await transportation would further tax resources by doubling the average amount of time spent by police with each patient. We agree with the hospitals that the solution is not more police officers, but rather more and better health care. Specifically, patients need to be evaluated much quicker as to the cause of their illness (drugs, alcohol, or mental health) and the patients need to be transferred, where appropriate to a detoxification center or a mental health facility. Having patients come to a hospital emergency room, waiting much too long for evaluation, and having a police officer sit in an emergency room and spend time with that patient for hours and hours is a poor use of the public’s limited resources and is not a solution to the premature closure of the County’s Mental Health Facility. Response from the City of Anderson (received August 18, 2005): Just like the Grand Jury, the City of Anderson, as well as our Chief of Police, are very concerned about public safety. As such, we cannot guarantee that Anderson Police Department (APD) officers can attend to 5150-designated patients “until they are transferred from local ‘unlocked’ emergency rooms.” To meet this recommendation, police officers would need top be diverted from our neighborhoods and businesses to attend to individuals who 12 should be at a detoxification center or at a mental health facility for a minimum of several hours and/or as much as twenty-four to thirty hours. Diverting officers from their patrol duties would not guarantee public safety, but instead would decrease public safety in our own neighborhoods by reducing the number of officers available for law enforcement. Typically, ADP deploys two to three officers on each twelve-hour shift. These officers’s primary responsibility is the safety and security of the Community of Anderson. Currently, when an arrest is made, or a 5150-designated patient is taken into civil arrest custody, the shift coverage is reduced to two officers, and too often to just one officer, remaining in the City. Obviously this represents not only an “officer safety” issue but a “community safety” issue as well. Currently, an ADP officer will remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to himself or herself or anyone else. Since the premature closure of the Shasta County Mental Psychiatric Facility, without adequate planning, the amount of time a police officer must spend at the hospitals handling 5150-designated patient calls has already increased. Remaining at the hospital to await transfer, as recommended by the Grand Jury, would further tax APD’s resources, typically doubling the average amount of time spent by the officer with each 5150-designated patient. The Anderson City Council appreciates the opportunity to respond to Grand Jury Recommendation Number 12 and hopes that our response is helpful. Response from the City of Shasta Lake (received July 28, 2005): The City of Shasta Lake agrees with the recommendation. Law enforcement services for the City of Shasta Lake are provided by the Shasta County Sheriff’s Department. The Sheriff has provided these services since the City’s incorporation in 1993. It is currently the policy of the Shasta County Sheriff’s department to provide law enforcement personnel to attend 5150-designated persons while they are treated in, and until they are transferred from local unlocked emergency rooms. GJ Reply to the Responses: The Grand Jury accepts the responses from the representatives of law enforcement in the County. We acknowledge the extra time and cost of attending to 5150-designated patients. We remain concerned that persons, who by definition are a risk to themselves or others, even when stabilized, are left unattended in area emergency rooms. A potential for harm within the hospital setting, or after a 5150 designee decides to leave against medical advice, remains a public safety issue.
R13:
The MHAB needs broader community representation. Private physician, local hospital and clinic, and law enforcement inclusion would strengthen the MHAB role as the community advocate for mental health issues. The Grand Jury encourages the BOS to improve the MHAB composition and strongly urges the MHAB to carefully review all major contracts entered into by SCMH. Response from the BOS: the BOS concurs with the Grand Jury’s recommendation regarding the expansion of community representation on the Mental Health Board. The Chairperson will work with the Mental Health Board Membership Committee to recruit a broader cross-section of community members. The MHAB will continue to review the State Department of Mental Health Performance Contract, which governs aspects of the operations of the SCMH Department before it is submitted to the BOS for approval. GJ Reply to the Response: The Grand Jury is satisfied with the response and again encourages MHAB input on all major contracts entered into by SCMH.
R14:
Citizens of Shasta County can take advantage of a new source of state funding for expanded mental health services through the Mental Health Services Act. Similar to new library construction funding a few years ago, this Act awards state tax revenues to individual or joint county proposals for services based on the merits of the plans submitted. Shasta County citizens rallied impressively to support the library and the Grand Jury strongly recommends the BOS encourage a similar community effort. This is an excellent opportunity for increasing access to local services that are both desperately needed and chronically under funded. Mental health services should be prioritized through the public input sessions sponsored by SCMH. The BOS and MHAB should incorporate this community input into any proposal being submitted. Response from the BOS: The BOS concurs with the Grand Jury recommendations regarding the Mental Health Services Act. GJ Reply to the Response: The Grand Jury appreciates the response. The Grand Jury is concerned that a broad community effort to mobilize for real change in local mental health service delivery is not a priority. The BOS consistently ignores community needs for access to local inpatient care by allowing SCMH to export inpatients to out-of-county facilities. While purporting to support the active integration of mental illness into mainstream medicine, BOS policies and SCMH decisions continue to impede this integration. If the BOS, SCMH and area providers cannot unite to address this problem, it is unlikely that cohesive community support will follow.
R15:
The BOS should not rely entirely on staff recommendations when considering future funding and direction of mental health policy in Shasta County. Assigning large, long-term, mo-bid contracts for untried services (Elpida) and closing the super PHF against the recommendations of the MHAB and a citizen’s Community Committee do not represent the best interests of County residents. Since the prior BOS (with the exception of one member) felt economic considerations superceded community recommendations to maintain an inpatient facility, the Grand jury encourages the current BOS (with two new members) to reexamine the issue. From the data presented in this 14 report, the Grand Jury recommends the BOS reconsider the economic factors that led to the decision to close the PHF. We fully appreciate the patient safety issues of the inpatient facility as it was configured prior to its closure. However, our investigation indicates that reopening a basic PHF (non-Medicare) with strict admission criteria is an economically viable and safe alternative to having no local locked inpatient facility at all. Establishing appropriate and affordable local inpatient hospital services would improve patient access ands care and alleviate the problems generated by the closure of the PHF. In conclusion, the Shasta county Grand jury asks the BOS to examine all the facts and govern for its constituents, and not for what benefits SCMH. Response from the BOS: The BOS does not rely solely on the recommendations of staff when considering funding or policy changes. The Board follows an extensive process of review to include a departmental staff report, County Administrative Office review and concurrence, County Counsel review, and Risk Management review. In addition, the Board receives and considers constituent feedback, including Advisory Board input, and public input regarding all Shasta County issues. The BOS voted 4-1 to close the PHF after considering all of the information and several factors including patient safety due to the lack of emergency medical care and the subsequent exposure to litigation. Continued operation of the PHF would require significant funding reductions in other areas of the Mental Health Department. Mental Health Outpatient services would have to be eliminated to ensure the ongoing financial viability of the inpatient unit. Discontinuing outpatient treatment programs would impact a larger population than the closure of the PHF. The loss of outpatient treatment services would impact approximately 87 percent of the total SCMH patient population receiving preventative services, case management, therapy, life management skills, medical management skills, counseling, and other specialty services that minimize or eliminate the need for emergency mental health treatment. Without outpatient treatment the need for emergency mental health treatment services would increase exponentially and exceed the capacity of the PHF. The legal, social, and fiscal impact on law enforcement, social support agencies, and the community in general would be significant. The Grand jury recommendation states that the Elpida contract was a large, long-term, no-bid contract for untried services. The initial term for the Elpida Crisis Residential contract commenced July 1, 2004, and ended on June 30, 2005. The contract was renewed for the same term length for fiscal year 2005-2006 on July 1, 2005. The Elpida Crisis Recovery Center is a subsidiary organization of Crestwood behavioral Health, Inc. Shasta County has had many contractual agreements with Crestwood for similar residential psychiatric services. The Elpida contract was approved by the Board in an amount not to exceed $1,124,200. This amount represents a cost savings for inpatient services that were provided at the PHF. GJ Reply to the Response: The Grand Jury disagrees with the response. With the exception of this final recommendation, all the responses received from the BOS 15 appear to have been provided solely by SCMH; they are taken almost verbatim from a set of responses received earlier from the SCMH Director. This is an indication of a continued over-reliance on staff recommendations. We feel compelled to point out that the Elpida Center is not licensed as a locked inpatient acute care facility (i.e., a PHF) and is not similar to other Shasta County- Crestwood psychiatric ventures. And although some patients are transferred from local emergency rooms directly to Elpida, it remains our contention that expenditures for this facility do little to address the need of County residents for acute inpatient treatment. The Grand Jury remains convinced that developing our own inpatient services is preferable to renting them. We contend that reopening a basic PHF is economically viable, as the yearly cost for a similar facility in Butte County is around $2 million. This represents less than 10 percent of the total SCMH budget, and less than the County is now spending for Elpida and out-of-county inpatient facilities. It is our belief that this will not impact the delivery of outpatient mental health services as described in the response. Conclusion: Prior to, and since the release of our report, public interest in the delivery of mental health services to County residents continues to make news. In April 2005, the BOS held a workshop on mental health issues and listened to patient and provider complaints. In May, the BOS, in conjunction with local hospitals and the Shasta Community Health Center, agreed to seek funding for an outside consultant to review the operations of SCMH. The Grand Jury commends the review and hopes its findings will lead to an improved delivery of care. In July, SCMH psychiatrists finally applied for privileges at one local hospital, but not at the other. A claimed “lack of collegiality” at the hospitals was offered as the reason SCMH physicians had not previously applied for privileges. An unfriendly response is not a reason to seek or deny privileges, nor has it prevented other specialists from attempting to do so. This slow pace of psychiatrist integration into general medicine, and a similar disinterest of the medical community to “buy-in” to the public delivery of mental health care provided by SCMH, remains a significant obstacle to further progress. For example, the declining interest in establishing a joint-partnership, community- sponsored, detoxification center underscores the level of mistrust between providers, SCMH and local government. The integration of mental illness into mainstream medicine cannot occur without willing and effective leadership from all sides. Over the summer months, anecdotal stories from citizens about their inability to access care at SCMH continued to be heard by the BOS. Claims by SCMH administrators that “payer source” is not a factor in the decision to treat patients have been contradicted by both community physicians and families. The Grand 16 Jury remains concerned that there will be no resolution of SCMH bureaucracy and, therefore, gaps in coverage will continue. On a positive note, SCMH will hold a Mental Health Services Act (Proposition 63) public hearing and release its community action plan for funding in October. The Grand Jury applauds the effort by SCMH in soliciting broad community involvement over the past year and looks forward to the presentation of the plan. A major goal of our report was to expand the community discussion about mental health. We believe this has been accomplished. However, discussion is only the first step. Productive action by local government is still lacking. Even with re-opening an inpatient facility, the poor communication between SCMH and the medical community, the ongoing problems with patient access, and an overly bureaucratic mental health department, continue to stymie progress. Report No. 3: Redding Land Purchases The Grand Jury reported on the increasing number of land purchases by the City of Redding, specifically the purchase of an 82-acre vacant parcel along Interstate 5. The parcel, ostensibly purchased as a buffer zone to the City’s southern boundary, is situated mostly in a flood plain and lies outside the city limits. The $1.5 million purchase was funded by a loan to the City’s general fund from the Redding Electric Utility (REU) reserve fund. The report also focused on the use of Redevelopment funding for the purchase of two other properties. The City of Redding responded to four recommendations by letter submitted to the presiding judge of the Superior Court by the Mayor of Redding on July 20, 2005.
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Findings & Recommendations
19 findings
F1:
The Grand Jury’s review of the independent audit reports for fiscal years 1999/2000, 2000/2001, 2001/2002 and 2002/2003 revealed the following deficiencies in the independent auditor’s report: a. The Schedule of Funded Status (retirement funds for employees) for SCSD states “Information Not Available” in each report since 1998. This information has been available from the California Public Employees Retirement System. b. The Government National Mortgage Association (GNMA) investment as listed on the June 30, 2003 audit showed a cost basis of $30,832 and a market value of $769. The independent auditor stated that SCSD has received principal payments over the years of $30,099, reducing the current cost basis to $733 versus a current market value of $769. c. The Management Letters did not show, how and when the prior years’
F2:
The SCSD Board was advised during audit presentations in 2002 and 2003 that under Government Accounting Standards Board Statement 34 (GASB 34) requirements the district’s financial statements would have to follow a new format to reflect physical inventory and valuation by June 30, 2004.
F3:
On December 18, 2003, the SCSD Board approved payment of a bill for $142.89 from a business in which one of the members of the SCSD Board is a co-partner. All five members of the Board voted to approve payment of that bill, which was among a slate of several bills submitted to the SCSD Board for its consideration. Section 1090 of the California Government Code prohibits a public official, such as a member of the board of directors of a community services district, from having a financial interest in any contract entered into by the board of which he/she is a member, even if the official does not vote on the contract. It also prohibits the board from entering into such a contract. The payment of the bill from the business in which a member of the SCSD was a co-partner constituted a contract in which the board member has a financial interest. The action taken by the SCSD Board on December 18, 2003 was improper. A contract made in violation of section 1090 is void. Any payments made to the contracting party must be returned to the public entity and the entity is entitled to retain any benefits it had received.
F4:
On December 13, 2000, four of the five members of the SCSD Board of Directors voted to appoint a new fire chief, a paid position. The person who was appointed is the spouse of the board member who was not present at this meeting. As noted above, section 1090 of the Government Code prohibits public officers from being financially interested in contracts made by them in their official capacity, or made by boards of which they are members. Hiring of an employee constitutes a contract covered by the provisions of section 1090. Moreover, even if the board member did not vote on the appointment, the SCSD Board should not have appointed the fire chief as long as his/her spouse serves on the Board. In addition to the prohibition against public officials making contracts in which they have a financial interest, a contract made in violation of section 1090 of the Government Code is void. Any payments made to the contracting party pursuant to a contract made in violation of section 1090 must be returned and no claim for future payment under the contract may be made.
F5:
SCSD employees get paid once a month, but frequently make a mid-month draw on their wages.
F6:
A new draft Policy and Procedures manual is under development to update existing policies and procedures. The Grand Jury found that: • Many current practices do not follow existing policies and procedures • Laws have changed and some existing polices need revision • Existing policies and files are stored in various locations • The district needs to have written policies and procedures where none exists (i.e. appraisal of personnel, personnel grievances, pre-employment physical and drug testing, maintaining list of employees and contractors, reporting on- the-job injuries, taking disciplinary action, and cash handling and deposits).
F7:
The bills presented to the SCSD Board for approval have a minimal description, requiring the Board to spend too much time asking for clarification during the bill approval process.
F8:
The purchasing of materials is not done in an orderly, cost-effective manner. Rather than planning for bulk purchases, staff makes frequent shopping trips.
F9:
The SCSD does not have a credit card policy and has cards for companies no longer in business.
F10:
The Investment Performance Report is not submitted to the SCSD Board on a quarterly basis as required by the General Manager’s job description.
F11:
The SCSD is not in compliance with three regulations contained in the California Code of Regulations (CCR), at Title 8, General Industry Safety Orders. Specifically: a. Confined Spaces (sections 5156 through 5158): This article prescribes minimum standards for preventing employee exposure to confined space hazards within such spaces as silos and tanks. During the SCSD facility tour, the Grand Jury observed numerous water storage tanks which are covered by the article because each tank: • Is large enough and so configured that an employee can bodily enter and perform assigned work, and • has limited or restricted means for entry or exit and • is not designed for continuous employee occupancy. SCSD employees told the Grand Jury that they do enter these storage tanks. The article requires the employer to inform employees performing work in the area, by posting danger signs or by any other equally effective means, of the existence, location of and the danger posed by the confined spaces. If the employer decides that its employees should not enter a confined space the employer must take effective measures to prevent entrance. If the employer decides that its employees will enter a confined space, the employer must develop and implement a written program that complies with the article. The Grand Jury did not observe any posted warning signs as required by the code. The Grand Jury requested SCSD provide a copy of its written program, but it was not provided and the Grand Jury did not find any evidence that this document exists. b. Excavations (sections 1540 and 1541): These sections apply to trenches, which are defined as an excavation where the depth is greater than the width but less than fifteen feet. The Grand Jury was shown pictures of an excavation done by SCSD where the depth was obviously over 5 feet because a man was standing in it and the sides were higher than he was tall. The regulations require employee protection from cave-ins, unless excavations are made in entirely stable rock, or are less than five feet in depth and examination of the ground by a competent person provides no indication of potential cave-in. The Grand Jury was not provided any evidence in interviews with SCSD employees that these protections were provided nor do the pictures provide such evidence. c. Fall protection (section 3210): Guard rails must be provided on all open sides of unenclosed work locations more than 30 inches above the floor or ground. There is an exception, if employees use the elevated location infrequently and are protected by an authorized fall restraint/fall arrest system. The Grand Jury observed that access ladders were attached to most storage tanks but in only one case was a guardrail installed on the top of the tank. Only one of the other tanks had a locked restriction on the ladder to prevent its use. SCSD did not provide evidence of a fall protection plan, training or equipment.
F12:
The Grand Jury observed that the containers in which hazardous materials were being stored were not labeled. Those containers included: • A fire department waste oil tank • Chlorine liquid containers at various locations • Water treatment facility polymer storage containers
F13:
Effective January 1, 2004, SCSD was required to file a Business Plan with the Shasta County Environmental Health Department (California Health and Safety Code Section 25503), relating to the handling of hazardous materials. SCSD has not filed the required plan. Guidelines for preparation of a plan are available from the Environmental Health Department’s Hazardous Materials Management division.
F14:
During the tour of SCSD facilities the Grand Jury observed that wastewater is discharged from the filter plant into backwash ponds. The SCSD has not filed an Application/Report of Waste Discharge (ROWD) with the Regional Water Quality Control Board (RWQCB). California Water Code Section 13260 states that persons discharging waste that could affect the quality of the waters of the State, other than into a community sewer system, must file a ROWD providing information which may be required by the appropriate RWQCB. The necessary forms are available upon request from the RWQCB.
F15:
The access to the pressure-reducing vault located in Records Heights is not secure.
F16:
Chlorine gas supplies are not adequately secured at the water treatment facility to prevent theft, vandalism or terrorist acts.
F17:
In 2003, the SCSD Board and Water Department employees participated in only one of many available seminars, workshops, conferences and professional organization meetings.
F18:
The last Insurance Services Office (ISO) report was issued November 1, 1985. SCSD received a 57.93% credit, earning a Public Protection Class 5 rating. Premiums charged to homeowners and businesses for fire protection insurance are lower if the credit is higher (60-100%).
F19:
The SCSD Board approved and adopted on November 20, 2003 a Master Water Plan prepared by Pace Civil Inc. The plan gives the SCSD Board direction on providing water service to the district’s customers for the next 20 years.
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Findings & Recommendations
19 findings
F1:
The Grand Jury had lunch prepared by the cadets. The kitchen/dining hall, barracks, workshops and campgrounds were clean and well maintained. During the tour, the Grand Jury looked for signs of graffiti; none was found.
F2:
The BOC Inspection Report of June 2003 states that funds available for staffing are only enough to license 45 of the possible 60-bed capacity.
F3:
The average number of cadets at the camp is 42 and the average length of their stay is 90-120 days.
F4:
Vocational programs such as learning work skills in construction, computer assembly and repair and food preparation are available. The cadets gain practical experience while working on various projects in the community. These team activities help to promote a good work ethic and responsibility. The cadets are also provided the opportunity to obtain their General Education Diploma. School attendance is required three days a week, six hours per day. The following special programs are available to the cadets for readjustment into the community: • Anger Management • Gang Awareness • Construction Trades • Job Skills • Culinary Arts • Leadership Skills • Domestic Violence • Life Skills • Drug and Alcohol • Victim Awareness • First-Aid and CPR
F5:
One of the three Crystal Creek Regional Boys’ Camp classrooms is not being used due to lack of funding for a teacher and an aide. The position of Mental Health Counselor is unfilled, due to lack of funding. Other counties pay Shasta County for the cadets that they assign to the camp. The rate varies from $58 to $76 per day with 65% of the counties paying the higher rate. To meet the budgetary goals, the camp needs an average of 26 cadets per day from other counties. At the time of the Grand Jury visit the number of cadets from other counties was 21, which has been the average since June
F6:
The District continues to maintain accounts that are significantly past due. In the fiscal year 2001/2002 annual audit of the District, it was recommended that old accounts be aggressively collected or “written off” as bad debt. The District has not implemented this recommendation.
F7:
In the 2000/2001, 2001/2002 and 2002/2003 annual audits, the auditing firm noted that the District’s bond agreements require that certain amounts be maintained by the District as reserve or restricted cash to meet current interest and principal requirements. The audit report reviewed by the Grand Jury recommended accounts for note funds, reserve funds, operation and maintenance funds, and a surplus fund. The District has not implemented this
F8:
During the interviews, employees and board members told the Grand Jury that payroll advances were seldom used. However, the auditing firm provided a ledger prepared by the District showing 39 payroll advances during fiscal year 2002/2003. In all of the annual audits reviewed by the Grand Jury, the auditing firm recommended discontinuing the practice of payroll advances. The District has not implemented this recommendation.
F9:
The District has no formal policy for purchasing those items needed for the District’s use. The District maintains several open charge accounts at various local businesses.
F10:
The District uses two cellular phones for general communication. The Grand Jury reviewed three months of cellular phone bills and found that they were in excess of $300 per month.
F11:
The District has no long-term Master Water Plan. A Master Water Plan is an engineering study of the water system that includes preliminary plans with scheduling and cost estimates for future system maintenance, repairs, equipment replacements, and major capital improvements. A plan helps ensure that the community’s present and future water quality and supply needs are met in an efficient and economical matter. This practice allows the District to properly prepare and budget for its future needs.
F12:
The District does not maintain an accurate subsidiary ledger of customer deposits. This list shows customer deposits since the 1970’s. All annual audits reviewed by the Grand Jury recommended that the District update the customer deposit ledger. The District has not implemented this recommendation.
F13:
The District does not maintain an accurate subsidiary ledger of inventory and does not have a process in place for an annual inventory. The fiscal year 2002/2003 audit recommended the District keep a year-end fiscal inventory and maintains an inventory subsidiary ledger. The District has not implemented this
F14:
The District has had to sell off a portion of its investments each year to service the District’s operating expenses. This is depleting the cash balance of the District. The District does not generate sufficient revenue to cover debt service on the 1973 and 1979 bonds and the 1973 Drought Relief loan. The debt service for fiscal year 2003/2004 is $42,782.00. Annual audits reviewed by the Grand Jury recommended that the District take the steps necessary to generate sufficient revenue to cover debt service and operating expenses without depleting cash reserves. The District increased water and sewer rates by 15% in August 2001 and by 20% in November 2003. The former District Manager and the Auditors stated that the rate increases would be insufficient to cover the District’s expenses.
F15:
For the fiscal years ended June 30, 2001, 2002 and 2003, the District had an excess of expenses over revenue of $84,912, $70,034 and $82,041 respectively.
F16:
Chlorine gas supplies are not adequately secured at the water treatment facility to prevent theft, vandalism or terrorist acts.
F17:
In 2003, the SCSD Board and Water Department employees participated in only one of many available seminars, workshops, conferences and professional organization meetings.
F18:
The last Insurance Services Office (ISO) report was issued November 1, 1985. SCSD received a 57.93% credit, earning a Public Protection Class 5 rating. Premiums charged to homeowners and businesses for fire protection insurance are lower if the credit is higher (60-100%).
F19:
The SCSD Board approved and adopted on November 20, 2003 a Master Water Plan prepared by Pace Civil Inc. The plan gives the SCSD Board direction on providing water service to the district’s customers for the next 20 years.
Additional Recommendations
14
Not linked to specific findings.
R1:
The City Council should not derail well designed Infill and Planned Developments. Response: Concur, if they meet the General Plan and other development policies as determined by the public’s elected representatives who are selected to make these decisions. The Grand Jury’s finding on this matter (No. 6) has substantial factual errors. The City Council determined that the project was not consistent with the General Plan. The design of the project contained aspects that did not comply with the General Plan policy. GJ Reply to the Response: The Grand Jury finds the City Council’s response unacceptable. The Grand Jury determined that the project was consistent with the General Plan. Furthermore, if “…the project was not consistent with the General Plan,” as stated above, then it should not have been approved by the Planning Department in the first place.
R2:
The Planning Department should attempt to expedite the permit approval process. The City’s Ombudsman report on recommended process changes should continue to be implemented. Response: Grand Jury Finding No. 9 states that “the City’s Ombudsman Report on Recommended Process Changes was presented to the City Council for consideration on October 25, 2004. …Some of these recommendations are being implemented by the City’s Development Services Department.” In fact, all of these measures are being implemented with the exception of the permit tracking system. The tracking system is extremely expensive, which is why it has taken longer than the other points mentioned in the Grand Jury’s findings. However, the City Council will be discussing this issue as the City looks at planning and engineering fee increases in the next few months. GJ Reply to the Response: The Grand Jury finds the response acceptable and looks forward to the implementation of the permit tracking system.
R3:
Political influence should not override sound planning decisions. Response: Concur. Grand Jury Finding No. 8 states that, “strong political influence was exerted on the Planning Commission and City Council to disapprove this project.” This is obviously a statement of opinion. It would be equally valid to say that strong political pressure was exerted on the Planning Commission and City Council to approve the 2 project. Concerns for and against projects will very likely continue as the City entertains more infill projects. GJ Reply to the Response: The Grand Jury finds the response acceptable. However, it remains our “opinion” that the front-row presence of McConnell Foundation executives at the City Council meeting regarding opposition to this project represented undue “strong political influence” against the project’s approval. Report No. 2: Haste Makes Waste In a lengthy report, the 2004/2005 Grand Jury investigated the closure of the Shasta County Psychiatric Hospital Facility (PHF) and its impact on inpatient care of the acutely mentally ill. The overall operation of the Shasta County Mental Health Department (SCMH) was also investigated. The required response from the Shasta County Board of Supervisors (BOS) was sent to the presiding judge of the superior court on September 27, 2005. The Director of SCMH was also invited to respond to certain recommendations; the response was received on August 29, 2005.
R4:
The Shasta County BOS should consider privatizing, in part or in total, the delivery of mental health services to the citizens of the county. With proper oversight, this would offer a more efficient overall operation. Assurances that all patients requiring treatment actually receive treatment would be necessary. The Grand Jury feels an extensive and well-planned transition program, with input from the general public and all providers of mental healthcare delivery, must precede any transfer from public to private operation. Response from the BOS: Currently 54 percent of the SCMH budget is devoted to contract services, and this has consistently increased over the past 2-3 fiscal years. As a result, SCMH is more than half “privatized.” With each contract for services entered into by the BOS, SCMH must assure that services are delivered in accordance with State Department of Mental Health requirements, which govern target population, service delivery, and the receipt of State and federal funds. SCMH provides mental health services to the residents of Shasta County in compliance with three State Department of Mental Health contracts. These contracts include very specific terms and conditions and are renewed annually with the approval of the BOS. (A one-page description of the contracts accompanied the response). The Grand Jury notes in its findings a number of perceptions regarding the role of SCMH in the delivery and authorization of inpatient mental health services that are not consistent with this contract and SCMH’s practice. The first and most important misperception is related to access to psychiatric hospitalization for all Medi-Cal eligible Shasta county residents. There are no pre-authorization requirements for emergency admissions to psychiatric inpatient hospitals for Shasta County Medi-Cal beneficiaries. SCMH provides post-admission review of written Treatment Authorization Requests submitted by hospitals as required by the State prior to payment by EDS (Electronic Data Systems). Since SCMH is no longer a provider of psychiatric hospital services, independent practitioners affiliated with the private treating facilities now make the determination of the patient’s admission and continued stay. GJ Reply to the Response: The Grand Jury disagrees with the response. The intent of the recommendation was to consider privatizing the entire mental health delivery system in Shasta County, including its administration. The privatization discussed by the BOS was, in part, necessitated by the closure of the PHF; patients who require hospitalization for acute mental illness now need to be hospitalized out-of- county (i.e., “privatized”). SCMH does serve as the managed care provider and pre-authorizer for Medi-Cal beneficiaries in Shasta County. This was confirmed by the SCMH Director (on two occasions), Deputy Director, and by multiple psychiatrists during the investigation; the Director of the NVMA concurred during a public forum held by the BOS in April 2005.
R5:
The Grand Jury recommends the SCMH Director improve lines of communication to ensure that SCMH policies affecting the medical community and other public agencies are uniform and consistent. We encourage SCMH to continue to improve access to its crisis intervention teams to reduce emergency room transfer delays. Moreover, to improve the continuity of patient care, we suggest that SCMH expedite the transfer of medical information (history, diagnosis and prescriptions) along with patients requiring out-of-county care. Conversely, SCMH should demand that discharge summaries accompany its patients returning from out-of-county facilities. Additionally, 6 the Grand Jury discourages the indiscriminate delegation of 5150 authority by the SCMH Director. Response from the SCMH Director: SCMH concurs with the recommendation regarding communication with the medical community and out of county facilities. SCMH will promote collaborative efforts with the NVMA to provide education and training for area physicians regarding the treatment of psychiatric illness. As stated in Response No. 3, another solution to the local emergency department congestion and transfer time delays is the implementation of a coordinated case management system that will provide wraparound medical and behavioral healthcare, and psychosocial supports to a population identified as frequent utilizers of the Mental Health emergency response system. SCMH, in collaboration with North State counties, looks forward to the opening of the North Valley Behavioral Health and Sequoia Psychiatric Center PHF in Yuba City, both of which will exclusively treat our patients. This will greatly enhance the continuity of care and communication of critical patient care issues on admission and discharge for Shasta County patients. GJ Reply to the Response: The Grand Jury generally agrees with the response, however, the indiscriminate delegation of 5150 authority was not addressed.
R6:
SCMH should establish written cost-sharing policies with the County Jail, Juvenile Hall, Probation department and other agencies for inpatient care and transportation of their mentally impaired inmates or clients. SCMH should improve its service to county agencies affected by the PHF closure, e.g. attend to inmates at the Main Jail and Juvenile Hall. Response from the SCMH Director: The Shasta County Sheriff’s Department and Probation Department maintain a contract with Prison Health Services for the provision of health and mental health services in the jail and juvenile hall. This contract is comprehensive in scope and specifies the responsibility of the provider in the provision of all planned and urgent medical services, including psychiatry. The contract includes the responsibility of the provider for reimbursement of hospital services for inmates and wards in custody, but excludes the contact provider from responsibility for reimbursement for psychiatric hospitalization. As a result, there is a serious gap in coverage for jail inmates in custody and juvenile wards in custody. SCMH works cooperatively with jail and juvenile hall staff to address this gap on a case-by-case basis, following written protocols that were developed collaboratively between the Sheriff’s Department, Probation Department, and Mental Health. SCMH also provides the services of a psychologist in juvenile hall and SHIFT (Shasta Housing Intervention For Transition) Program services in the jail to assist Prison Health Services and the courts with inmate/ward mental health issues. GJ Reply to the Response: The above response is inadequate. It does not address transportation protocols and/or cost sharing between SCMH and incarceration facilities since the closure of the PHF. The problem of court ordered on-site psychiatric evaluations is also not addressed. Jail representatives were unable to produce written protocols for inmate evaluation and treatment.
R7:
The BOS and SCMH should closely monitor the costs (including all transportation costs) of out-of-county inpatient care. The Grand Jury offers the following options for reestablishing inpatient psychiatric services for which the County still holds State licensure: iReopen the 15-bed PHF at the previous site on Breslauer Way by deleting its Medicare designation and adopting strict admission criteria for adult inpatients. This would reduce the average daily cost of care by 50 percent (to $2 million per year) and also minimize patient safety issues. Medicare inpatients requiring hospitalization would be cared for at other facilities. iOpen a 15-bed basic PHF on Breslauer way as a combined adult/child inpatient facility by designating 10 beds for adults and five for children. iOpen a 15-bed basic PHF on Breslauer as the only north state child inpatient facility. Costs would be more manageable and there is a very low risk of associated physical co- morbidity in this age group. The BOS should obtain sufficient information to determine whether or not to renew the SCMH $1.3 million yearly contract for the Elpida Crisis Residential Center. Any option to reopen a PHF would necessitate either closing or relocating this center. The Grand jury recommends closure. In that event, inpatient psychiatric services could be funded using current SCMH revenues generated by increasing efficiency, reducing out-of-county inpatient care, substituting primary care practitioners for some psychiatrists and eliminating costly Medicare staffing. Moreover, additional funding may become available beginning in 2005/2006 through the Mental Health Services Act. The Grand Jury believes that County residents could, and should, have local access to both inpatient and outpatient mental health services. Inpatient child psychiatric services have been identified as woefully inadequate for decades and the Grand Jury invites Shasta County to take the initiative and establish a child/adolescent inpatient facility. A north state regional, multi-county proposal for Mental Health Services Act funds (perhaps orchestrated by the SCMH Director) could establish a geographically centered, acute care facility for children with mental impairment. Benefits of such a facility to the overall mental health of children include earlier recognition and treatment of impairment and an improved continuity of care. Enhanced case management, better social rehabilitative services, access to intensive family psychotherapy and recruitment of more child psychiatrists could result from a successful program. This is an opportune time for Shasta County to address the psychiatric needs of north state children. Response from the BOS: SCMH has submitted the planned budget to the Shasta County Administrative Office including projected expenditures and revenues for fiscal year 2005/2006. In this budget, the SCMH department does not recommend that it operate a staff a psychiatric health facility during fiscal year 2005/2006. The BOS concurs that an involuntary mental health acute care inpatient unit is needed in Shasta County but realizes that patient safety is of the utmost importance. In an effort to meet the medical needs of all patients, the delivery of mental health treatment services (involuntary or voluntary) should be integrated with emergency and primary health care. The County PHF was not licensed to provide emergency medical or primary health care services, therefore, reopening the facility is not viable. SCMH, in collaboration with the Shasta County Administrative Office and the North Valley Medical Association (NVMA), has facilitated contacts between interested providers of inpatient behavioral health services and the administrators of the local general hospitals. The goal of this collaboration is to integrate acute care psychiatry into mainstream primary health care so that those suffering from mental illness have the opportunity to receive treatment for all of their medical needs in an environment where they are not stigmatized or isolated form medical care. The BOS agrees that a regional approach to specialty psychiatric care is viable for target populations. An example of the potential in this area is the soon to open North Valley Behavioral and Sequoia Psychiatric Center PHF. SCMH has taken a strong leadership role in this 4-year effort and the SCMH Director sits on the steering committee that has been responsible for the planning and implementation of these facilities. Specifically regarding the viability of a regional facility for children, SCMH has promoted three regional options. The first option was the establishment of a regional locked community treatment facility, which was not supported at a regional level. The second option was the dedication of one of the new regional psychiatric facilities to children, which was also not regionally supported. The third option is the establishment of a regional interagency crisis assessment center for children. This option may be considered as a priority focus under the Mental Health Services Act. GJ Reply to the Response: The Grand Jury disagrees with the response. Adequate revenue exists for the reestablishment of a local, scaled-down (i.e., non-Medicare) PHF. Strict admission criteria would greatly reduce patient safety issues. The BOS talks of integrated care, but the SCMH Director’s responses to recommendations 2, 3 and 5 above, do little to promote integration with primary health care. The BOS response claims the County PHF is not licensed for emergency medical or primary health care and therefore, reopening it is not a viable option. The Grand Jury notes that while none of the State PHFs are licensed for emergency medical or primary health care services, they continue to provide acute psychiatric inpatient care. The Grand Jury further notes that the North Valley Behavioral and Sequoia Psychiatric Center, to which Shasta County sends inpatients for treatment, is not a full-service hospital providing integrated health care. Moreover, the BOS response does not address the recommended closure of the Elpida Crisis Center. The Grand Jury suggests that the BOS need only look as far as Butte County to consider a functioning non-Medicare designated PHF. The Butte County PHF exists because of support by both the general public and the Butte County Mental Health Director. The integration with mainstream medical care for their patients with co-morbidities is easily obtained because of a positive relationship with the medical community of that County.
R8:
Other inpatient psychiatric services could include: iThe reopening of inpatient services for Medicare patients at a local rehabilitation facility. iA truly collaborative effort between SCMH and the local medical community too begin laying the groundwork for an inpatient psychiatric unit in one of the local full-service hospitals. Response from the BOS: The Shasta County BOS concurs with the recommendation that a local inpatient facility should be pursued. This facility should have the capacity to treat patients flexibly, which is best done in a licensed general hospital. SCMH, in conjunction with the Shasta County Administrative Office, has facilitated contracts with three corporations that are providers of behavioral health services that would like to develop a local inpatient facility. At a recent presentation, one provider made it clear that the provision of behavioral health services in a licensed general hospital with more than 100 beds is financially viable and of economic benefit to the hospital. NVMA representatives have made it contact with this provider and will facilitate meetings in an effort to promote the proposal, gain support from local hospitals, and encourage community involvement in this potential opportunity. GJ Reply to the Response: The Grand Jury accepts the response and awaits the outcome of this potential effort. The SCMH department is working with the NVMA to facilitate contacts between interested psychiatric providers and local hospitals. The Grand Jury applauds this portion of the response, but as noted in our report, the establishment of a psychiatric unit in a local full-service hospital is a three-year process.
R10:
The Grand Jury suggests that the BOS pay a site visit to the County-contracted Elpida Crisis Residential Center and closely evaluate the benefits of the contract’s automatic renewal after fiscal year 2004/2005. Should Elpida remain open, the Grand Jury also recommends adoption of a formal lease between the County and Elpida’s private sponsor and establishment of an Elpida Policies and Procedures Manual. Response from the BOS: Representatives from the BOS, County Administrative Office, and Mental Health Advisory Board participated in a tour of the Elpida Crisis Residential Center on September 7, 2005, as recommended by the Grand jury. The Elpida crisis residential Center maintains a policy and procedures manual that addresses the areas required by State regulation. GJ Reply to the Response: The Grand Jury finds the response inadequate. Only two Supervisors participated in the Elpida tour and no evaluation of the benefit of extending the contract was made. The response did not address a lease between the County and Elpida’s private sponsor. The Grand Jury is still awaiting receipt of the Policy and Procedures Manual from Elpida.
R11:
The Grand Jury recommends the County BOS and SCMH consider both financial and staffing support of a proposed County Detoxification Center. This center would afford opportunity for an improved collaboration between SCMH and both the local medical community and city governments. Establishment of a detoxification center would reduce the congestion in local hospital emergency rooms. Mental Health Services Act (Proposition 63) funding could be an additional source of financial support. Response from the BOS: The BOS, SCMH, and the Shasta County Alcohol and Drug Programs (SCADP) are in complete support of expanding the social model detoxification program in Shasta County. This is consistent with the “Community Action Plan” developed by representatives of Mercy Medical Center, Shasta Regional Medical Center, Shasta Community Health Center, the Good News Rescue Mission, SCMH, and the SCADP. A memorandum of understanding (MOU) has been developed by SCADP and circulated to the participants and other recommended collaborative partners. To date, only the City of Shasta Lake and the Shasta County Administrative Office have responded with support. The role of the Mental Health Services Act (Proposition 63) funding in this service expansion will be determined once the State Department of Mental Health guidelines for application for funding have been finalized and distributed. Additionally, the input received from stakeholders at more than 30 State required focus groups, conducted by SCMH, must be considered when prioritizing areas of need for mental health services expansion. This process targeted for completion in October to allow for a timely submission to the State Department of Mental Health. GJ Reply to the Response: The Grand Jury is satisfied with the response. We are also discouraged that only two collaborators have committed financially to a project that received unanimous support from all interviewees.
R12:
The Grand Jury recommends that County and City Government guarantee public safety at all times by ensuring law enforcement personnel attend to 11 5150-designated patients while they are treated in, and until they are transferred from, local “unlocked” emergency rooms. Response from the BOS: The process for transfer of law enforcement 5150 detentions is governed by an interagency agreement developed by local law enforcement agencies in collaboration with representatives of SCMH, Shasta regional Medical Center, Mercy Medical Center, and Mayers Memorial Hospital District. Less than half of the calls to the emergency departments are the result of this process. More than half of the calls for SCMH crisis response are for patients who have presented to the emergency departments without law enforcement involvement. Thus, law enforcement personnel are not present in these cases while the emergency department examines the patient to determine if an emergency medical condition exists consistent with the federal requirements under the Emergency Medical Treatment and Labor Act. In these cases, SCMH determines the legal status of the patient if the emergency department physician decides that transfer or discharge to a specialty psychiatric facility is necessary. Response from the City of Redding: The Grand Jury recommendation requires further analysis. The Police Chief cannot guarantee that law enforcement personnel attend to 5150-designated patients while they are “treated in, and until they are transferred from, local unlocked emergency rooms.” It would mean that police officers would need to be diverted from our neighborhoods and businesses to attend to individuals who should be at a detoxification center or at a mental health facility for as much as 24 to 30 hours. Currently, police officers remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to themselves or anyone else. Since the closure of the County PHF, police time necessary to handle these calls has already increased 66%. Remaining at the hospital to await transportation would further tax resources by doubling the average amount of time spent by police with each patient. We agree with the hospitals that the solution is not more police officers, but rather more and better health care. Specifically, patients need to be evaluated much quicker as to the cause of their illness (drugs, alcohol, or mental health) and the patients need to be transferred, where appropriate to a detoxification center or a mental health facility. Having patients come to a hospital emergency room, waiting much too long for evaluation, and having a police officer sit in an emergency room and spend time with that patient for hours and hours is a poor use of the public’s limited resources and is not a solution to the premature closure of the County’s Mental Health Facility. Response from the City of Anderson (received August 18, 2005): Just like the Grand Jury, the City of Anderson, as well as our Chief of Police, are very concerned about public safety. As such, we cannot guarantee that Anderson Police Department (APD) officers can attend to 5150-designated patients “until they are transferred from local ‘unlocked’ emergency rooms.” To meet this recommendation, police officers would need top be diverted from our neighborhoods and businesses to attend to individuals who 12 should be at a detoxification center or at a mental health facility for a minimum of several hours and/or as much as twenty-four to thirty hours. Diverting officers from their patrol duties would not guarantee public safety, but instead would decrease public safety in our own neighborhoods by reducing the number of officers available for law enforcement. Typically, ADP deploys two to three officers on each twelve-hour shift. These officers’s primary responsibility is the safety and security of the Community of Anderson. Currently, when an arrest is made, or a 5150-designated patient is taken into civil arrest custody, the shift coverage is reduced to two officers, and too often to just one officer, remaining in the City. Obviously this represents not only an “officer safety” issue but a “community safety” issue as well. Currently, an ADP officer will remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to himself or herself or anyone else. Since the premature closure of the Shasta County Mental Psychiatric Facility, without adequate planning, the amount of time a police officer must spend at the hospitals handling 5150-designated patient calls has already increased. Remaining at the hospital to await transfer, as recommended by the Grand Jury, would further tax APD’s resources, typically doubling the average amount of time spent by the officer with each 5150-designated patient. The Anderson City Council appreciates the opportunity to respond to Grand Jury Recommendation Number 12 and hopes that our response is helpful. Response from the City of Shasta Lake (received July 28, 2005): The City of Shasta Lake agrees with the recommendation. Law enforcement services for the City of Shasta Lake are provided by the Shasta County Sheriff’s Department. The Sheriff has provided these services since the City’s incorporation in 1993. It is currently the policy of the Shasta County Sheriff’s department to provide law enforcement personnel to attend 5150-designated persons while they are treated in, and until they are transferred from local unlocked emergency rooms. GJ Reply to the Responses: The Grand Jury accepts the responses from the representatives of law enforcement in the County. We acknowledge the extra time and cost of attending to 5150-designated patients. We remain concerned that persons, who by definition are a risk to themselves or others, even when stabilized, are left unattended in area emergency rooms. A potential for harm within the hospital setting, or after a 5150 designee decides to leave against medical advice, remains a public safety issue.
R13:
The MHAB needs broader community representation. Private physician, local hospital and clinic, and law enforcement inclusion would strengthen the MHAB role as the community advocate for mental health issues. The Grand Jury encourages the BOS to improve the MHAB composition and strongly urges the MHAB to carefully review all major contracts entered into by SCMH. Response from the BOS: the BOS concurs with the Grand Jury’s recommendation regarding the expansion of community representation on the Mental Health Board. The Chairperson will work with the Mental Health Board Membership Committee to recruit a broader cross-section of community members. The MHAB will continue to review the State Department of Mental Health Performance Contract, which governs aspects of the operations of the SCMH Department before it is submitted to the BOS for approval. GJ Reply to the Response: The Grand Jury is satisfied with the response and again encourages MHAB input on all major contracts entered into by SCMH.
R14:
Citizens of Shasta County can take advantage of a new source of state funding for expanded mental health services through the Mental Health Services Act. Similar to new library construction funding a few years ago, this Act awards state tax revenues to individual or joint county proposals for services based on the merits of the plans submitted. Shasta County citizens rallied impressively to support the library and the Grand Jury strongly recommends the BOS encourage a similar community effort. This is an excellent opportunity for increasing access to local services that are both desperately needed and chronically under funded. Mental health services should be prioritized through the public input sessions sponsored by SCMH. The BOS and MHAB should incorporate this community input into any proposal being submitted. Response from the BOS: The BOS concurs with the Grand Jury recommendations regarding the Mental Health Services Act. GJ Reply to the Response: The Grand Jury appreciates the response. The Grand Jury is concerned that a broad community effort to mobilize for real change in local mental health service delivery is not a priority. The BOS consistently ignores community needs for access to local inpatient care by allowing SCMH to export inpatients to out-of-county facilities. While purporting to support the active integration of mental illness into mainstream medicine, BOS policies and SCMH decisions continue to impede this integration. If the BOS, SCMH and area providers cannot unite to address this problem, it is unlikely that cohesive community support will follow.
R15:
The BOS should not rely entirely on staff recommendations when considering future funding and direction of mental health policy in Shasta County. Assigning large, long-term, mo-bid contracts for untried services (Elpida) and closing the super PHF against the recommendations of the MHAB and a citizen’s Community Committee do not represent the best interests of County residents. Since the prior BOS (with the exception of one member) felt economic considerations superceded community recommendations to maintain an inpatient facility, the Grand jury encourages the current BOS (with two new members) to reexamine the issue. From the data presented in this 14 report, the Grand Jury recommends the BOS reconsider the economic factors that led to the decision to close the PHF. We fully appreciate the patient safety issues of the inpatient facility as it was configured prior to its closure. However, our investigation indicates that reopening a basic PHF (non-Medicare) with strict admission criteria is an economically viable and safe alternative to having no local locked inpatient facility at all. Establishing appropriate and affordable local inpatient hospital services would improve patient access ands care and alleviate the problems generated by the closure of the PHF. In conclusion, the Shasta county Grand jury asks the BOS to examine all the facts and govern for its constituents, and not for what benefits SCMH. Response from the BOS: The BOS does not rely solely on the recommendations of staff when considering funding or policy changes. The Board follows an extensive process of review to include a departmental staff report, County Administrative Office review and concurrence, County Counsel review, and Risk Management review. In addition, the Board receives and considers constituent feedback, including Advisory Board input, and public input regarding all Shasta County issues. The BOS voted 4-1 to close the PHF after considering all of the information and several factors including patient safety due to the lack of emergency medical care and the subsequent exposure to litigation. Continued operation of the PHF would require significant funding reductions in other areas of the Mental Health Department. Mental Health Outpatient services would have to be eliminated to ensure the ongoing financial viability of the inpatient unit. Discontinuing outpatient treatment programs would impact a larger population than the closure of the PHF. The loss of outpatient treatment services would impact approximately 87 percent of the total SCMH patient population receiving preventative services, case management, therapy, life management skills, medical management skills, counseling, and other specialty services that minimize or eliminate the need for emergency mental health treatment. Without outpatient treatment the need for emergency mental health treatment services would increase exponentially and exceed the capacity of the PHF. The legal, social, and fiscal impact on law enforcement, social support agencies, and the community in general would be significant. The Grand jury recommendation states that the Elpida contract was a large, long-term, no-bid contract for untried services. The initial term for the Elpida Crisis Residential contract commenced July 1, 2004, and ended on June 30, 2005. The contract was renewed for the same term length for fiscal year 2005-2006 on July 1, 2005. The Elpida Crisis Recovery Center is a subsidiary organization of Crestwood behavioral Health, Inc. Shasta County has had many contractual agreements with Crestwood for similar residential psychiatric services. The Elpida contract was approved by the Board in an amount not to exceed $1,124,200. This amount represents a cost savings for inpatient services that were provided at the PHF. GJ Reply to the Response: The Grand Jury disagrees with the response. With the exception of this final recommendation, all the responses received from the BOS 15 appear to have been provided solely by SCMH; they are taken almost verbatim from a set of responses received earlier from the SCMH Director. This is an indication of a continued over-reliance on staff recommendations. We feel compelled to point out that the Elpida Center is not licensed as a locked inpatient acute care facility (i.e., a PHF) and is not similar to other Shasta County- Crestwood psychiatric ventures. And although some patients are transferred from local emergency rooms directly to Elpida, it remains our contention that expenditures for this facility do little to address the need of County residents for acute inpatient treatment. The Grand Jury remains convinced that developing our own inpatient services is preferable to renting them. We contend that reopening a basic PHF is economically viable, as the yearly cost for a similar facility in Butte County is around $2 million. This represents less than 10 percent of the total SCMH budget, and less than the County is now spending for Elpida and out-of-county inpatient facilities. It is our belief that this will not impact the delivery of outpatient mental health services as described in the response. Conclusion: Prior to, and since the release of our report, public interest in the delivery of mental health services to County residents continues to make news. In April 2005, the BOS held a workshop on mental health issues and listened to patient and provider complaints. In May, the BOS, in conjunction with local hospitals and the Shasta Community Health Center, agreed to seek funding for an outside consultant to review the operations of SCMH. The Grand Jury commends the review and hopes its findings will lead to an improved delivery of care. In July, SCMH psychiatrists finally applied for privileges at one local hospital, but not at the other. A claimed “lack of collegiality” at the hospitals was offered as the reason SCMH physicians had not previously applied for privileges. An unfriendly response is not a reason to seek or deny privileges, nor has it prevented other specialists from attempting to do so. This slow pace of psychiatrist integration into general medicine, and a similar disinterest of the medical community to “buy-in” to the public delivery of mental health care provided by SCMH, remains a significant obstacle to further progress. For example, the declining interest in establishing a joint-partnership, community- sponsored, detoxification center underscores the level of mistrust between providers, SCMH and local government. The integration of mental illness into mainstream medicine cannot occur without willing and effective leadership from all sides. Over the summer months, anecdotal stories from citizens about their inability to access care at SCMH continued to be heard by the BOS. Claims by SCMH administrators that “payer source” is not a factor in the decision to treat patients have been contradicted by both community physicians and families. The Grand 16 Jury remains concerned that there will be no resolution of SCMH bureaucracy and, therefore, gaps in coverage will continue. On a positive note, SCMH will hold a Mental Health Services Act (Proposition 63) public hearing and release its community action plan for funding in October. The Grand Jury applauds the effort by SCMH in soliciting broad community involvement over the past year and looks forward to the presentation of the plan. A major goal of our report was to expand the community discussion about mental health. We believe this has been accomplished. However, discussion is only the first step. Productive action by local government is still lacking. Even with re-opening an inpatient facility, the poor communication between SCMH and the medical community, the ongoing problems with patient access, and an overly bureaucratic mental health department, continue to stymie progress. Report No. 3: Redding Land Purchases The Grand Jury reported on the increasing number of land purchases by the City of Redding, specifically the purchase of an 82-acre vacant parcel along Interstate 5. The parcel, ostensibly purchased as a buffer zone to the City’s southern boundary, is situated mostly in a flood plain and lies outside the city limits. The $1.5 million purchase was funded by a loan to the City’s general fund from the Redding Electric Utility (REU) reserve fund. The report also focused on the use of Redevelopment funding for the purchase of two other properties. The City of Redding responded to four recommendations by letter submitted to the presiding judge of the Superior Court by the Mayor of Redding on July 20, 2005.
Findings & Recommendations
19 findings
F1:
The Grand Jury had lunch prepared by the cadets. The kitchen/dining hall, barracks, workshops and campgrounds were clean and well maintained. During the tour, the Grand Jury looked for signs of graffiti; none was found.
F2:
The BOC Inspection Report of June 2003 states that funds available for staffing are only enough to license 45 of the possible 60-bed capacity.
F3:
The average number of cadets at the camp is 42 and the average length of their stay is 90-120 days.
F4:
Vocational programs such as learning work skills in construction, computer assembly and repair and food preparation are available. The cadets gain practical experience while working on various projects in the community. These team activities help to promote a good work ethic and responsibility. The cadets are also provided the opportunity to obtain their General Education Diploma. School attendance is required three days a week, six hours per day. The following special programs are available to the cadets for readjustment into the community: • Anger Management • Gang Awareness • Construction Trades • Job Skills • Culinary Arts • Leadership Skills • Domestic Violence • Life Skills • Drug and Alcohol • Victim Awareness • First-Aid and CPR
F5:
One of the three Crystal Creek Regional Boys’ Camp classrooms is not being used due to lack of funding for a teacher and an aide. The position of Mental Health Counselor is unfilled, due to lack of funding. Other counties pay Shasta County for the cadets that they assign to the camp. The rate varies from $58 to $76 per day with 65% of the counties paying the higher rate. To meet the budgetary goals, the camp needs an average of 26 cadets per day from other counties. At the time of the Grand Jury visit the number of cadets from other counties was 21, which has been the average since June
F6:
The District continues to maintain accounts that are significantly past due. In the fiscal year 2001/2002 annual audit of the District, it was recommended that old accounts be aggressively collected or “written off” as bad debt. The District has not implemented this recommendation.
F7:
In the 2000/2001, 2001/2002 and 2002/2003 annual audits, the auditing firm noted that the District’s bond agreements require that certain amounts be maintained by the District as reserve or restricted cash to meet current interest and principal requirements. The audit report reviewed by the Grand Jury recommended accounts for note funds, reserve funds, operation and maintenance funds, and a surplus fund. The District has not implemented this
F8:
During the interviews, employees and board members told the Grand Jury that payroll advances were seldom used. However, the auditing firm provided a ledger prepared by the District showing 39 payroll advances during fiscal year 2002/2003. In all of the annual audits reviewed by the Grand Jury, the auditing firm recommended discontinuing the practice of payroll advances. The District has not implemented this recommendation.
F9:
The District has no formal policy for purchasing those items needed for the District’s use. The District maintains several open charge accounts at various local businesses.
F10:
The District uses two cellular phones for general communication. The Grand Jury reviewed three months of cellular phone bills and found that they were in excess of $300 per month.
F11:
The District has no long-term Master Water Plan. A Master Water Plan is an engineering study of the water system that includes preliminary plans with scheduling and cost estimates for future system maintenance, repairs, equipment replacements, and major capital improvements. A plan helps ensure that the community’s present and future water quality and supply needs are met in an efficient and economical matter. This practice allows the District to properly prepare and budget for its future needs.
F12:
The District does not maintain an accurate subsidiary ledger of customer deposits. This list shows customer deposits since the 1970’s. All annual audits reviewed by the Grand Jury recommended that the District update the customer deposit ledger. The District has not implemented this recommendation.
F13:
The District does not maintain an accurate subsidiary ledger of inventory and does not have a process in place for an annual inventory. The fiscal year 2002/2003 audit recommended the District keep a year-end fiscal inventory and maintains an inventory subsidiary ledger. The District has not implemented this
F14:
The District has had to sell off a portion of its investments each year to service the District’s operating expenses. This is depleting the cash balance of the District. The District does not generate sufficient revenue to cover debt service on the 1973 and 1979 bonds and the 1973 Drought Relief loan. The debt service for fiscal year 2003/2004 is $42,782.00. Annual audits reviewed by the Grand Jury recommended that the District take the steps necessary to generate sufficient revenue to cover debt service and operating expenses without depleting cash reserves. The District increased water and sewer rates by 15% in August 2001 and by 20% in November 2003. The former District Manager and the Auditors stated that the rate increases would be insufficient to cover the District’s expenses.
F15:
For the fiscal years ended June 30, 2001, 2002 and 2003, the District had an excess of expenses over revenue of $84,912, $70,034 and $82,041 respectively.
F16:
Chlorine gas supplies are not adequately secured at the water treatment facility to prevent theft, vandalism or terrorist acts.
F17:
In 2003, the SCSD Board and Water Department employees participated in only one of many available seminars, workshops, conferences and professional organization meetings.
F18:
The last Insurance Services Office (ISO) report was issued November 1, 1985. SCSD received a 57.93% credit, earning a Public Protection Class 5 rating. Premiums charged to homeowners and businesses for fire protection insurance are lower if the credit is higher (60-100%).
F19:
The SCSD Board approved and adopted on November 20, 2003 a Master Water Plan prepared by Pace Civil Inc. The plan gives the SCSD Board direction on providing water service to the district’s customers for the next 20 years.
Additional Recommendations
14
Not linked to specific findings.
R1:
The City Council should not derail well designed Infill and Planned Developments. Response: Concur, if they meet the General Plan and other development policies as determined by the public’s elected representatives who are selected to make these decisions. The Grand Jury’s finding on this matter (No. 6) has substantial factual errors. The City Council determined that the project was not consistent with the General Plan. The design of the project contained aspects that did not comply with the General Plan policy. GJ Reply to the Response: The Grand Jury finds the City Council’s response unacceptable. The Grand Jury determined that the project was consistent with the General Plan. Furthermore, if “…the project was not consistent with the General Plan,” as stated above, then it should not have been approved by the Planning Department in the first place.
R2:
The Planning Department should attempt to expedite the permit approval process. The City’s Ombudsman report on recommended process changes should continue to be implemented. Response: Grand Jury Finding No. 9 states that “the City’s Ombudsman Report on Recommended Process Changes was presented to the City Council for consideration on October 25, 2004. …Some of these recommendations are being implemented by the City’s Development Services Department.” In fact, all of these measures are being implemented with the exception of the permit tracking system. The tracking system is extremely expensive, which is why it has taken longer than the other points mentioned in the Grand Jury’s findings. However, the City Council will be discussing this issue as the City looks at planning and engineering fee increases in the next few months. GJ Reply to the Response: The Grand Jury finds the response acceptable and looks forward to the implementation of the permit tracking system.
R3:
Political influence should not override sound planning decisions. Response: Concur. Grand Jury Finding No. 8 states that, “strong political influence was exerted on the Planning Commission and City Council to disapprove this project.” This is obviously a statement of opinion. It would be equally valid to say that strong political pressure was exerted on the Planning Commission and City Council to approve the 2 project. Concerns for and against projects will very likely continue as the City entertains more infill projects. GJ Reply to the Response: The Grand Jury finds the response acceptable. However, it remains our “opinion” that the front-row presence of McConnell Foundation executives at the City Council meeting regarding opposition to this project represented undue “strong political influence” against the project’s approval. Report No. 2: Haste Makes Waste In a lengthy report, the 2004/2005 Grand Jury investigated the closure of the Shasta County Psychiatric Hospital Facility (PHF) and its impact on inpatient care of the acutely mentally ill. The overall operation of the Shasta County Mental Health Department (SCMH) was also investigated. The required response from the Shasta County Board of Supervisors (BOS) was sent to the presiding judge of the superior court on September 27, 2005. The Director of SCMH was also invited to respond to certain recommendations; the response was received on August 29, 2005.
R4:
The Shasta County BOS should consider privatizing, in part or in total, the delivery of mental health services to the citizens of the county. With proper oversight, this would offer a more efficient overall operation. Assurances that all patients requiring treatment actually receive treatment would be necessary. The Grand Jury feels an extensive and well-planned transition program, with input from the general public and all providers of mental healthcare delivery, must precede any transfer from public to private operation. Response from the BOS: Currently 54 percent of the SCMH budget is devoted to contract services, and this has consistently increased over the past 2-3 fiscal years. As a result, SCMH is more than half “privatized.” With each contract for services entered into by the BOS, SCMH must assure that services are delivered in accordance with State Department of Mental Health requirements, which govern target population, service delivery, and the receipt of State and federal funds. SCMH provides mental health services to the residents of Shasta County in compliance with three State Department of Mental Health contracts. These contracts include very specific terms and conditions and are renewed annually with the approval of the BOS. (A one-page description of the contracts accompanied the response). The Grand Jury notes in its findings a number of perceptions regarding the role of SCMH in the delivery and authorization of inpatient mental health services that are not consistent with this contract and SCMH’s practice. The first and most important misperception is related to access to psychiatric hospitalization for all Medi-Cal eligible Shasta county residents. There are no pre-authorization requirements for emergency admissions to psychiatric inpatient hospitals for Shasta County Medi-Cal beneficiaries. SCMH provides post-admission review of written Treatment Authorization Requests submitted by hospitals as required by the State prior to payment by EDS (Electronic Data Systems). Since SCMH is no longer a provider of psychiatric hospital services, independent practitioners affiliated with the private treating facilities now make the determination of the patient’s admission and continued stay. GJ Reply to the Response: The Grand Jury disagrees with the response. The intent of the recommendation was to consider privatizing the entire mental health delivery system in Shasta County, including its administration. The privatization discussed by the BOS was, in part, necessitated by the closure of the PHF; patients who require hospitalization for acute mental illness now need to be hospitalized out-of- county (i.e., “privatized”). SCMH does serve as the managed care provider and pre-authorizer for Medi-Cal beneficiaries in Shasta County. This was confirmed by the SCMH Director (on two occasions), Deputy Director, and by multiple psychiatrists during the investigation; the Director of the NVMA concurred during a public forum held by the BOS in April 2005.
R5:
The Grand Jury recommends the SCMH Director improve lines of communication to ensure that SCMH policies affecting the medical community and other public agencies are uniform and consistent. We encourage SCMH to continue to improve access to its crisis intervention teams to reduce emergency room transfer delays. Moreover, to improve the continuity of patient care, we suggest that SCMH expedite the transfer of medical information (history, diagnosis and prescriptions) along with patients requiring out-of-county care. Conversely, SCMH should demand that discharge summaries accompany its patients returning from out-of-county facilities. Additionally, 6 the Grand Jury discourages the indiscriminate delegation of 5150 authority by the SCMH Director. Response from the SCMH Director: SCMH concurs with the recommendation regarding communication with the medical community and out of county facilities. SCMH will promote collaborative efforts with the NVMA to provide education and training for area physicians regarding the treatment of psychiatric illness. As stated in Response No. 3, another solution to the local emergency department congestion and transfer time delays is the implementation of a coordinated case management system that will provide wraparound medical and behavioral healthcare, and psychosocial supports to a population identified as frequent utilizers of the Mental Health emergency response system. SCMH, in collaboration with North State counties, looks forward to the opening of the North Valley Behavioral Health and Sequoia Psychiatric Center PHF in Yuba City, both of which will exclusively treat our patients. This will greatly enhance the continuity of care and communication of critical patient care issues on admission and discharge for Shasta County patients. GJ Reply to the Response: The Grand Jury generally agrees with the response, however, the indiscriminate delegation of 5150 authority was not addressed.
R6:
SCMH should establish written cost-sharing policies with the County Jail, Juvenile Hall, Probation department and other agencies for inpatient care and transportation of their mentally impaired inmates or clients. SCMH should improve its service to county agencies affected by the PHF closure, e.g. attend to inmates at the Main Jail and Juvenile Hall. Response from the SCMH Director: The Shasta County Sheriff’s Department and Probation Department maintain a contract with Prison Health Services for the provision of health and mental health services in the jail and juvenile hall. This contract is comprehensive in scope and specifies the responsibility of the provider in the provision of all planned and urgent medical services, including psychiatry. The contract includes the responsibility of the provider for reimbursement of hospital services for inmates and wards in custody, but excludes the contact provider from responsibility for reimbursement for psychiatric hospitalization. As a result, there is a serious gap in coverage for jail inmates in custody and juvenile wards in custody. SCMH works cooperatively with jail and juvenile hall staff to address this gap on a case-by-case basis, following written protocols that were developed collaboratively between the Sheriff’s Department, Probation Department, and Mental Health. SCMH also provides the services of a psychologist in juvenile hall and SHIFT (Shasta Housing Intervention For Transition) Program services in the jail to assist Prison Health Services and the courts with inmate/ward mental health issues. GJ Reply to the Response: The above response is inadequate. It does not address transportation protocols and/or cost sharing between SCMH and incarceration facilities since the closure of the PHF. The problem of court ordered on-site psychiatric evaluations is also not addressed. Jail representatives were unable to produce written protocols for inmate evaluation and treatment.
R7:
The BOS and SCMH should closely monitor the costs (including all transportation costs) of out-of-county inpatient care. The Grand Jury offers the following options for reestablishing inpatient psychiatric services for which the County still holds State licensure: iReopen the 15-bed PHF at the previous site on Breslauer Way by deleting its Medicare designation and adopting strict admission criteria for adult inpatients. This would reduce the average daily cost of care by 50 percent (to $2 million per year) and also minimize patient safety issues. Medicare inpatients requiring hospitalization would be cared for at other facilities. iOpen a 15-bed basic PHF on Breslauer way as a combined adult/child inpatient facility by designating 10 beds for adults and five for children. iOpen a 15-bed basic PHF on Breslauer as the only north state child inpatient facility. Costs would be more manageable and there is a very low risk of associated physical co- morbidity in this age group. The BOS should obtain sufficient information to determine whether or not to renew the SCMH $1.3 million yearly contract for the Elpida Crisis Residential Center. Any option to reopen a PHF would necessitate either closing or relocating this center. The Grand jury recommends closure. In that event, inpatient psychiatric services could be funded using current SCMH revenues generated by increasing efficiency, reducing out-of-county inpatient care, substituting primary care practitioners for some psychiatrists and eliminating costly Medicare staffing. Moreover, additional funding may become available beginning in 2005/2006 through the Mental Health Services Act. The Grand Jury believes that County residents could, and should, have local access to both inpatient and outpatient mental health services. Inpatient child psychiatric services have been identified as woefully inadequate for decades and the Grand Jury invites Shasta County to take the initiative and establish a child/adolescent inpatient facility. A north state regional, multi-county proposal for Mental Health Services Act funds (perhaps orchestrated by the SCMH Director) could establish a geographically centered, acute care facility for children with mental impairment. Benefits of such a facility to the overall mental health of children include earlier recognition and treatment of impairment and an improved continuity of care. Enhanced case management, better social rehabilitative services, access to intensive family psychotherapy and recruitment of more child psychiatrists could result from a successful program. This is an opportune time for Shasta County to address the psychiatric needs of north state children. Response from the BOS: SCMH has submitted the planned budget to the Shasta County Administrative Office including projected expenditures and revenues for fiscal year 2005/2006. In this budget, the SCMH department does not recommend that it operate a staff a psychiatric health facility during fiscal year 2005/2006. The BOS concurs that an involuntary mental health acute care inpatient unit is needed in Shasta County but realizes that patient safety is of the utmost importance. In an effort to meet the medical needs of all patients, the delivery of mental health treatment services (involuntary or voluntary) should be integrated with emergency and primary health care. The County PHF was not licensed to provide emergency medical or primary health care services, therefore, reopening the facility is not viable. SCMH, in collaboration with the Shasta County Administrative Office and the North Valley Medical Association (NVMA), has facilitated contacts between interested providers of inpatient behavioral health services and the administrators of the local general hospitals. The goal of this collaboration is to integrate acute care psychiatry into mainstream primary health care so that those suffering from mental illness have the opportunity to receive treatment for all of their medical needs in an environment where they are not stigmatized or isolated form medical care. The BOS agrees that a regional approach to specialty psychiatric care is viable for target populations. An example of the potential in this area is the soon to open North Valley Behavioral and Sequoia Psychiatric Center PHF. SCMH has taken a strong leadership role in this 4-year effort and the SCMH Director sits on the steering committee that has been responsible for the planning and implementation of these facilities. Specifically regarding the viability of a regional facility for children, SCMH has promoted three regional options. The first option was the establishment of a regional locked community treatment facility, which was not supported at a regional level. The second option was the dedication of one of the new regional psychiatric facilities to children, which was also not regionally supported. The third option is the establishment of a regional interagency crisis assessment center for children. This option may be considered as a priority focus under the Mental Health Services Act. GJ Reply to the Response: The Grand Jury disagrees with the response. Adequate revenue exists for the reestablishment of a local, scaled-down (i.e., non-Medicare) PHF. Strict admission criteria would greatly reduce patient safety issues. The BOS talks of integrated care, but the SCMH Director’s responses to recommendations 2, 3 and 5 above, do little to promote integration with primary health care. The BOS response claims the County PHF is not licensed for emergency medical or primary health care and therefore, reopening it is not a viable option. The Grand Jury notes that while none of the State PHFs are licensed for emergency medical or primary health care services, they continue to provide acute psychiatric inpatient care. The Grand Jury further notes that the North Valley Behavioral and Sequoia Psychiatric Center, to which Shasta County sends inpatients for treatment, is not a full-service hospital providing integrated health care. Moreover, the BOS response does not address the recommended closure of the Elpida Crisis Center. The Grand Jury suggests that the BOS need only look as far as Butte County to consider a functioning non-Medicare designated PHF. The Butte County PHF exists because of support by both the general public and the Butte County Mental Health Director. The integration with mainstream medical care for their patients with co-morbidities is easily obtained because of a positive relationship with the medical community of that County.
R8:
Other inpatient psychiatric services could include: iThe reopening of inpatient services for Medicare patients at a local rehabilitation facility. iA truly collaborative effort between SCMH and the local medical community too begin laying the groundwork for an inpatient psychiatric unit in one of the local full-service hospitals. Response from the BOS: The Shasta County BOS concurs with the recommendation that a local inpatient facility should be pursued. This facility should have the capacity to treat patients flexibly, which is best done in a licensed general hospital. SCMH, in conjunction with the Shasta County Administrative Office, has facilitated contracts with three corporations that are providers of behavioral health services that would like to develop a local inpatient facility. At a recent presentation, one provider made it clear that the provision of behavioral health services in a licensed general hospital with more than 100 beds is financially viable and of economic benefit to the hospital. NVMA representatives have made it contact with this provider and will facilitate meetings in an effort to promote the proposal, gain support from local hospitals, and encourage community involvement in this potential opportunity. GJ Reply to the Response: The Grand Jury accepts the response and awaits the outcome of this potential effort. The SCMH department is working with the NVMA to facilitate contacts between interested psychiatric providers and local hospitals. The Grand Jury applauds this portion of the response, but as noted in our report, the establishment of a psychiatric unit in a local full-service hospital is a three-year process.
R10:
The Grand Jury suggests that the BOS pay a site visit to the County-contracted Elpida Crisis Residential Center and closely evaluate the benefits of the contract’s automatic renewal after fiscal year 2004/2005. Should Elpida remain open, the Grand Jury also recommends adoption of a formal lease between the County and Elpida’s private sponsor and establishment of an Elpida Policies and Procedures Manual. Response from the BOS: Representatives from the BOS, County Administrative Office, and Mental Health Advisory Board participated in a tour of the Elpida Crisis Residential Center on September 7, 2005, as recommended by the Grand jury. The Elpida crisis residential Center maintains a policy and procedures manual that addresses the areas required by State regulation. GJ Reply to the Response: The Grand Jury finds the response inadequate. Only two Supervisors participated in the Elpida tour and no evaluation of the benefit of extending the contract was made. The response did not address a lease between the County and Elpida’s private sponsor. The Grand Jury is still awaiting receipt of the Policy and Procedures Manual from Elpida.
R11:
The Grand Jury recommends the County BOS and SCMH consider both financial and staffing support of a proposed County Detoxification Center. This center would afford opportunity for an improved collaboration between SCMH and both the local medical community and city governments. Establishment of a detoxification center would reduce the congestion in local hospital emergency rooms. Mental Health Services Act (Proposition 63) funding could be an additional source of financial support. Response from the BOS: The BOS, SCMH, and the Shasta County Alcohol and Drug Programs (SCADP) are in complete support of expanding the social model detoxification program in Shasta County. This is consistent with the “Community Action Plan” developed by representatives of Mercy Medical Center, Shasta Regional Medical Center, Shasta Community Health Center, the Good News Rescue Mission, SCMH, and the SCADP. A memorandum of understanding (MOU) has been developed by SCADP and circulated to the participants and other recommended collaborative partners. To date, only the City of Shasta Lake and the Shasta County Administrative Office have responded with support. The role of the Mental Health Services Act (Proposition 63) funding in this service expansion will be determined once the State Department of Mental Health guidelines for application for funding have been finalized and distributed. Additionally, the input received from stakeholders at more than 30 State required focus groups, conducted by SCMH, must be considered when prioritizing areas of need for mental health services expansion. This process targeted for completion in October to allow for a timely submission to the State Department of Mental Health. GJ Reply to the Response: The Grand Jury is satisfied with the response. We are also discouraged that only two collaborators have committed financially to a project that received unanimous support from all interviewees.
R12:
The Grand Jury recommends that County and City Government guarantee public safety at all times by ensuring law enforcement personnel attend to 11 5150-designated patients while they are treated in, and until they are transferred from, local “unlocked” emergency rooms. Response from the BOS: The process for transfer of law enforcement 5150 detentions is governed by an interagency agreement developed by local law enforcement agencies in collaboration with representatives of SCMH, Shasta regional Medical Center, Mercy Medical Center, and Mayers Memorial Hospital District. Less than half of the calls to the emergency departments are the result of this process. More than half of the calls for SCMH crisis response are for patients who have presented to the emergency departments without law enforcement involvement. Thus, law enforcement personnel are not present in these cases while the emergency department examines the patient to determine if an emergency medical condition exists consistent with the federal requirements under the Emergency Medical Treatment and Labor Act. In these cases, SCMH determines the legal status of the patient if the emergency department physician decides that transfer or discharge to a specialty psychiatric facility is necessary. Response from the City of Redding: The Grand Jury recommendation requires further analysis. The Police Chief cannot guarantee that law enforcement personnel attend to 5150-designated patients while they are “treated in, and until they are transferred from, local unlocked emergency rooms.” It would mean that police officers would need to be diverted from our neighborhoods and businesses to attend to individuals who should be at a detoxification center or at a mental health facility for as much as 24 to 30 hours. Currently, police officers remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to themselves or anyone else. Since the closure of the County PHF, police time necessary to handle these calls has already increased 66%. Remaining at the hospital to await transportation would further tax resources by doubling the average amount of time spent by police with each patient. We agree with the hospitals that the solution is not more police officers, but rather more and better health care. Specifically, patients need to be evaluated much quicker as to the cause of their illness (drugs, alcohol, or mental health) and the patients need to be transferred, where appropriate to a detoxification center or a mental health facility. Having patients come to a hospital emergency room, waiting much too long for evaluation, and having a police officer sit in an emergency room and spend time with that patient for hours and hours is a poor use of the public’s limited resources and is not a solution to the premature closure of the County’s Mental Health Facility. Response from the City of Anderson (received August 18, 2005): Just like the Grand Jury, the City of Anderson, as well as our Chief of Police, are very concerned about public safety. As such, we cannot guarantee that Anderson Police Department (APD) officers can attend to 5150-designated patients “until they are transferred from local ‘unlocked’ emergency rooms.” To meet this recommendation, police officers would need top be diverted from our neighborhoods and businesses to attend to individuals who 12 should be at a detoxification center or at a mental health facility for a minimum of several hours and/or as much as twenty-four to thirty hours. Diverting officers from their patrol duties would not guarantee public safety, but instead would decrease public safety in our own neighborhoods by reducing the number of officers available for law enforcement. Typically, ADP deploys two to three officers on each twelve-hour shift. These officers’s primary responsibility is the safety and security of the Community of Anderson. Currently, when an arrest is made, or a 5150-designated patient is taken into civil arrest custody, the shift coverage is reduced to two officers, and too often to just one officer, remaining in the City. Obviously this represents not only an “officer safety” issue but a “community safety” issue as well. Currently, an ADP officer will remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to himself or herself or anyone else. Since the premature closure of the Shasta County Mental Psychiatric Facility, without adequate planning, the amount of time a police officer must spend at the hospitals handling 5150-designated patient calls has already increased. Remaining at the hospital to await transfer, as recommended by the Grand Jury, would further tax APD’s resources, typically doubling the average amount of time spent by the officer with each 5150-designated patient. The Anderson City Council appreciates the opportunity to respond to Grand Jury Recommendation Number 12 and hopes that our response is helpful. Response from the City of Shasta Lake (received July 28, 2005): The City of Shasta Lake agrees with the recommendation. Law enforcement services for the City of Shasta Lake are provided by the Shasta County Sheriff’s Department. The Sheriff has provided these services since the City’s incorporation in 1993. It is currently the policy of the Shasta County Sheriff’s department to provide law enforcement personnel to attend 5150-designated persons while they are treated in, and until they are transferred from local unlocked emergency rooms. GJ Reply to the Responses: The Grand Jury accepts the responses from the representatives of law enforcement in the County. We acknowledge the extra time and cost of attending to 5150-designated patients. We remain concerned that persons, who by definition are a risk to themselves or others, even when stabilized, are left unattended in area emergency rooms. A potential for harm within the hospital setting, or after a 5150 designee decides to leave against medical advice, remains a public safety issue.
R13:
The MHAB needs broader community representation. Private physician, local hospital and clinic, and law enforcement inclusion would strengthen the MHAB role as the community advocate for mental health issues. The Grand Jury encourages the BOS to improve the MHAB composition and strongly urges the MHAB to carefully review all major contracts entered into by SCMH. Response from the BOS: the BOS concurs with the Grand Jury’s recommendation regarding the expansion of community representation on the Mental Health Board. The Chairperson will work with the Mental Health Board Membership Committee to recruit a broader cross-section of community members. The MHAB will continue to review the State Department of Mental Health Performance Contract, which governs aspects of the operations of the SCMH Department before it is submitted to the BOS for approval. GJ Reply to the Response: The Grand Jury is satisfied with the response and again encourages MHAB input on all major contracts entered into by SCMH.
R14:
Citizens of Shasta County can take advantage of a new source of state funding for expanded mental health services through the Mental Health Services Act. Similar to new library construction funding a few years ago, this Act awards state tax revenues to individual or joint county proposals for services based on the merits of the plans submitted. Shasta County citizens rallied impressively to support the library and the Grand Jury strongly recommends the BOS encourage a similar community effort. This is an excellent opportunity for increasing access to local services that are both desperately needed and chronically under funded. Mental health services should be prioritized through the public input sessions sponsored by SCMH. The BOS and MHAB should incorporate this community input into any proposal being submitted. Response from the BOS: The BOS concurs with the Grand Jury recommendations regarding the Mental Health Services Act. GJ Reply to the Response: The Grand Jury appreciates the response. The Grand Jury is concerned that a broad community effort to mobilize for real change in local mental health service delivery is not a priority. The BOS consistently ignores community needs for access to local inpatient care by allowing SCMH to export inpatients to out-of-county facilities. While purporting to support the active integration of mental illness into mainstream medicine, BOS policies and SCMH decisions continue to impede this integration. If the BOS, SCMH and area providers cannot unite to address this problem, it is unlikely that cohesive community support will follow.
R15:
The BOS should not rely entirely on staff recommendations when considering future funding and direction of mental health policy in Shasta County. Assigning large, long-term, mo-bid contracts for untried services (Elpida) and closing the super PHF against the recommendations of the MHAB and a citizen’s Community Committee do not represent the best interests of County residents. Since the prior BOS (with the exception of one member) felt economic considerations superceded community recommendations to maintain an inpatient facility, the Grand jury encourages the current BOS (with two new members) to reexamine the issue. From the data presented in this 14 report, the Grand Jury recommends the BOS reconsider the economic factors that led to the decision to close the PHF. We fully appreciate the patient safety issues of the inpatient facility as it was configured prior to its closure. However, our investigation indicates that reopening a basic PHF (non-Medicare) with strict admission criteria is an economically viable and safe alternative to having no local locked inpatient facility at all. Establishing appropriate and affordable local inpatient hospital services would improve patient access ands care and alleviate the problems generated by the closure of the PHF. In conclusion, the Shasta county Grand jury asks the BOS to examine all the facts and govern for its constituents, and not for what benefits SCMH. Response from the BOS: The BOS does not rely solely on the recommendations of staff when considering funding or policy changes. The Board follows an extensive process of review to include a departmental staff report, County Administrative Office review and concurrence, County Counsel review, and Risk Management review. In addition, the Board receives and considers constituent feedback, including Advisory Board input, and public input regarding all Shasta County issues. The BOS voted 4-1 to close the PHF after considering all of the information and several factors including patient safety due to the lack of emergency medical care and the subsequent exposure to litigation. Continued operation of the PHF would require significant funding reductions in other areas of the Mental Health Department. Mental Health Outpatient services would have to be eliminated to ensure the ongoing financial viability of the inpatient unit. Discontinuing outpatient treatment programs would impact a larger population than the closure of the PHF. The loss of outpatient treatment services would impact approximately 87 percent of the total SCMH patient population receiving preventative services, case management, therapy, life management skills, medical management skills, counseling, and other specialty services that minimize or eliminate the need for emergency mental health treatment. Without outpatient treatment the need for emergency mental health treatment services would increase exponentially and exceed the capacity of the PHF. The legal, social, and fiscal impact on law enforcement, social support agencies, and the community in general would be significant. The Grand jury recommendation states that the Elpida contract was a large, long-term, no-bid contract for untried services. The initial term for the Elpida Crisis Residential contract commenced July 1, 2004, and ended on June 30, 2005. The contract was renewed for the same term length for fiscal year 2005-2006 on July 1, 2005. The Elpida Crisis Recovery Center is a subsidiary organization of Crestwood behavioral Health, Inc. Shasta County has had many contractual agreements with Crestwood for similar residential psychiatric services. The Elpida contract was approved by the Board in an amount not to exceed $1,124,200. This amount represents a cost savings for inpatient services that were provided at the PHF. GJ Reply to the Response: The Grand Jury disagrees with the response. With the exception of this final recommendation, all the responses received from the BOS 15 appear to have been provided solely by SCMH; they are taken almost verbatim from a set of responses received earlier from the SCMH Director. This is an indication of a continued over-reliance on staff recommendations. We feel compelled to point out that the Elpida Center is not licensed as a locked inpatient acute care facility (i.e., a PHF) and is not similar to other Shasta County- Crestwood psychiatric ventures. And although some patients are transferred from local emergency rooms directly to Elpida, it remains our contention that expenditures for this facility do little to address the need of County residents for acute inpatient treatment. The Grand Jury remains convinced that developing our own inpatient services is preferable to renting them. We contend that reopening a basic PHF is economically viable, as the yearly cost for a similar facility in Butte County is around $2 million. This represents less than 10 percent of the total SCMH budget, and less than the County is now spending for Elpida and out-of-county inpatient facilities. It is our belief that this will not impact the delivery of outpatient mental health services as described in the response. Conclusion: Prior to, and since the release of our report, public interest in the delivery of mental health services to County residents continues to make news. In April 2005, the BOS held a workshop on mental health issues and listened to patient and provider complaints. In May, the BOS, in conjunction with local hospitals and the Shasta Community Health Center, agreed to seek funding for an outside consultant to review the operations of SCMH. The Grand Jury commends the review and hopes its findings will lead to an improved delivery of care. In July, SCMH psychiatrists finally applied for privileges at one local hospital, but not at the other. A claimed “lack of collegiality” at the hospitals was offered as the reason SCMH physicians had not previously applied for privileges. An unfriendly response is not a reason to seek or deny privileges, nor has it prevented other specialists from attempting to do so. This slow pace of psychiatrist integration into general medicine, and a similar disinterest of the medical community to “buy-in” to the public delivery of mental health care provided by SCMH, remains a significant obstacle to further progress. For example, the declining interest in establishing a joint-partnership, community- sponsored, detoxification center underscores the level of mistrust between providers, SCMH and local government. The integration of mental illness into mainstream medicine cannot occur without willing and effective leadership from all sides. Over the summer months, anecdotal stories from citizens about their inability to access care at SCMH continued to be heard by the BOS. Claims by SCMH administrators that “payer source” is not a factor in the decision to treat patients have been contradicted by both community physicians and families. The Grand 16 Jury remains concerned that there will be no resolution of SCMH bureaucracy and, therefore, gaps in coverage will continue. On a positive note, SCMH will hold a Mental Health Services Act (Proposition 63) public hearing and release its community action plan for funding in October. The Grand Jury applauds the effort by SCMH in soliciting broad community involvement over the past year and looks forward to the presentation of the plan. A major goal of our report was to expand the community discussion about mental health. We believe this has been accomplished. However, discussion is only the first step. Productive action by local government is still lacking. Even with re-opening an inpatient facility, the poor communication between SCMH and the medical community, the ongoing problems with patient access, and an overly bureaucratic mental health department, continue to stymie progress. Report No. 3: Redding Land Purchases The Grand Jury reported on the increasing number of land purchases by the City of Redding, specifically the purchase of an 82-acre vacant parcel along Interstate 5. The parcel, ostensibly purchased as a buffer zone to the City’s southern boundary, is situated mostly in a flood plain and lies outside the city limits. The $1.5 million purchase was funded by a loan to the City’s general fund from the Redding Electric Utility (REU) reserve fund. The report also focused on the use of Redevelopment funding for the purchase of two other properties. The City of Redding responded to four recommendations by letter submitted to the presiding judge of the Superior Court by the Mayor of Redding on July 20, 2005.
Findings & Recommendations
19 findings
F1:
The Grand Jury had lunch prepared by the cadets. The kitchen/dining hall, barracks, workshops and campgrounds were clean and well maintained. During the tour, the Grand Jury looked for signs of graffiti; none was found.
F2:
The BOC Inspection Report of June 2003 states that funds available for staffing are only enough to license 45 of the possible 60-bed capacity.
F3:
The average number of cadets at the camp is 42 and the average length of their stay is 90-120 days.
F4:
Vocational programs such as learning work skills in construction, computer assembly and repair and food preparation are available. The cadets gain practical experience while working on various projects in the community. These team activities help to promote a good work ethic and responsibility. The cadets are also provided the opportunity to obtain their General Education Diploma. School attendance is required three days a week, six hours per day. The following special programs are available to the cadets for readjustment into the community: • Anger Management • Gang Awareness • Construction Trades • Job Skills • Culinary Arts • Leadership Skills • Domestic Violence • Life Skills • Drug and Alcohol • Victim Awareness • First-Aid and CPR
F5:
One of the three Crystal Creek Regional Boys’ Camp classrooms is not being used due to lack of funding for a teacher and an aide. The position of Mental Health Counselor is unfilled, due to lack of funding. Other counties pay Shasta County for the cadets that they assign to the camp. The rate varies from $58 to $76 per day with 65% of the counties paying the higher rate. To meet the budgetary goals, the camp needs an average of 26 cadets per day from other counties. At the time of the Grand Jury visit the number of cadets from other counties was 21, which has been the average since June
F6:
The District continues to maintain accounts that are significantly past due. In the fiscal year 2001/2002 annual audit of the District, it was recommended that old accounts be aggressively collected or “written off” as bad debt. The District has not implemented this recommendation.
F7:
In the 2000/2001, 2001/2002 and 2002/2003 annual audits, the auditing firm noted that the District’s bond agreements require that certain amounts be maintained by the District as reserve or restricted cash to meet current interest and principal requirements. The audit report reviewed by the Grand Jury recommended accounts for note funds, reserve funds, operation and maintenance funds, and a surplus fund. The District has not implemented this
F8:
During the interviews, employees and board members told the Grand Jury that payroll advances were seldom used. However, the auditing firm provided a ledger prepared by the District showing 39 payroll advances during fiscal year 2002/2003. In all of the annual audits reviewed by the Grand Jury, the auditing firm recommended discontinuing the practice of payroll advances. The District has not implemented this recommendation.
F9:
The District has no formal policy for purchasing those items needed for the District’s use. The District maintains several open charge accounts at various local businesses.
F10:
The District uses two cellular phones for general communication. The Grand Jury reviewed three months of cellular phone bills and found that they were in excess of $300 per month.
F11:
The District has no long-term Master Water Plan. A Master Water Plan is an engineering study of the water system that includes preliminary plans with scheduling and cost estimates for future system maintenance, repairs, equipment replacements, and major capital improvements. A plan helps ensure that the community’s present and future water quality and supply needs are met in an efficient and economical matter. This practice allows the District to properly prepare and budget for its future needs.
F12:
The District does not maintain an accurate subsidiary ledger of customer deposits. This list shows customer deposits since the 1970’s. All annual audits reviewed by the Grand Jury recommended that the District update the customer deposit ledger. The District has not implemented this recommendation.
F13:
The District does not maintain an accurate subsidiary ledger of inventory and does not have a process in place for an annual inventory. The fiscal year 2002/2003 audit recommended the District keep a year-end fiscal inventory and maintains an inventory subsidiary ledger. The District has not implemented this
F14:
The District has had to sell off a portion of its investments each year to service the District’s operating expenses. This is depleting the cash balance of the District. The District does not generate sufficient revenue to cover debt service on the 1973 and 1979 bonds and the 1973 Drought Relief loan. The debt service for fiscal year 2003/2004 is $42,782.00. Annual audits reviewed by the Grand Jury recommended that the District take the steps necessary to generate sufficient revenue to cover debt service and operating expenses without depleting cash reserves. The District increased water and sewer rates by 15% in August 2001 and by 20% in November 2003. The former District Manager and the Auditors stated that the rate increases would be insufficient to cover the District’s expenses.
F15:
For the fiscal years ended June 30, 2001, 2002 and 2003, the District had an excess of expenses over revenue of $84,912, $70,034 and $82,041 respectively.
F16:
Chlorine gas supplies are not adequately secured at the water treatment facility to prevent theft, vandalism or terrorist acts.
F17:
In 2003, the SCSD Board and Water Department employees participated in only one of many available seminars, workshops, conferences and professional organization meetings.
F18:
The last Insurance Services Office (ISO) report was issued November 1, 1985. SCSD received a 57.93% credit, earning a Public Protection Class 5 rating. Premiums charged to homeowners and businesses for fire protection insurance are lower if the credit is higher (60-100%).
F19:
The SCSD Board approved and adopted on November 20, 2003 a Master Water Plan prepared by Pace Civil Inc. The plan gives the SCSD Board direction on providing water service to the district’s customers for the next 20 years.
Additional Recommendations
14
Not linked to specific findings.
R1:
The City Council should not derail well designed Infill and Planned Developments. Response: Concur, if they meet the General Plan and other development policies as determined by the public’s elected representatives who are selected to make these decisions. The Grand Jury’s finding on this matter (No. 6) has substantial factual errors. The City Council determined that the project was not consistent with the General Plan. The design of the project contained aspects that did not comply with the General Plan policy. GJ Reply to the Response: The Grand Jury finds the City Council’s response unacceptable. The Grand Jury determined that the project was consistent with the General Plan. Furthermore, if “…the project was not consistent with the General Plan,” as stated above, then it should not have been approved by the Planning Department in the first place.
R2:
The Planning Department should attempt to expedite the permit approval process. The City’s Ombudsman report on recommended process changes should continue to be implemented. Response: Grand Jury Finding No. 9 states that “the City’s Ombudsman Report on Recommended Process Changes was presented to the City Council for consideration on October 25, 2004. …Some of these recommendations are being implemented by the City’s Development Services Department.” In fact, all of these measures are being implemented with the exception of the permit tracking system. The tracking system is extremely expensive, which is why it has taken longer than the other points mentioned in the Grand Jury’s findings. However, the City Council will be discussing this issue as the City looks at planning and engineering fee increases in the next few months. GJ Reply to the Response: The Grand Jury finds the response acceptable and looks forward to the implementation of the permit tracking system.
R3:
Political influence should not override sound planning decisions. Response: Concur. Grand Jury Finding No. 8 states that, “strong political influence was exerted on the Planning Commission and City Council to disapprove this project.” This is obviously a statement of opinion. It would be equally valid to say that strong political pressure was exerted on the Planning Commission and City Council to approve the 2 project. Concerns for and against projects will very likely continue as the City entertains more infill projects. GJ Reply to the Response: The Grand Jury finds the response acceptable. However, it remains our “opinion” that the front-row presence of McConnell Foundation executives at the City Council meeting regarding opposition to this project represented undue “strong political influence” against the project’s approval. Report No. 2: Haste Makes Waste In a lengthy report, the 2004/2005 Grand Jury investigated the closure of the Shasta County Psychiatric Hospital Facility (PHF) and its impact on inpatient care of the acutely mentally ill. The overall operation of the Shasta County Mental Health Department (SCMH) was also investigated. The required response from the Shasta County Board of Supervisors (BOS) was sent to the presiding judge of the superior court on September 27, 2005. The Director of SCMH was also invited to respond to certain recommendations; the response was received on August 29, 2005.
R4:
The Shasta County BOS should consider privatizing, in part or in total, the delivery of mental health services to the citizens of the county. With proper oversight, this would offer a more efficient overall operation. Assurances that all patients requiring treatment actually receive treatment would be necessary. The Grand Jury feels an extensive and well-planned transition program, with input from the general public and all providers of mental healthcare delivery, must precede any transfer from public to private operation. Response from the BOS: Currently 54 percent of the SCMH budget is devoted to contract services, and this has consistently increased over the past 2-3 fiscal years. As a result, SCMH is more than half “privatized.” With each contract for services entered into by the BOS, SCMH must assure that services are delivered in accordance with State Department of Mental Health requirements, which govern target population, service delivery, and the receipt of State and federal funds. SCMH provides mental health services to the residents of Shasta County in compliance with three State Department of Mental Health contracts. These contracts include very specific terms and conditions and are renewed annually with the approval of the BOS. (A one-page description of the contracts accompanied the response). The Grand Jury notes in its findings a number of perceptions regarding the role of SCMH in the delivery and authorization of inpatient mental health services that are not consistent with this contract and SCMH’s practice. The first and most important misperception is related to access to psychiatric hospitalization for all Medi-Cal eligible Shasta county residents. There are no pre-authorization requirements for emergency admissions to psychiatric inpatient hospitals for Shasta County Medi-Cal beneficiaries. SCMH provides post-admission review of written Treatment Authorization Requests submitted by hospitals as required by the State prior to payment by EDS (Electronic Data Systems). Since SCMH is no longer a provider of psychiatric hospital services, independent practitioners affiliated with the private treating facilities now make the determination of the patient’s admission and continued stay. GJ Reply to the Response: The Grand Jury disagrees with the response. The intent of the recommendation was to consider privatizing the entire mental health delivery system in Shasta County, including its administration. The privatization discussed by the BOS was, in part, necessitated by the closure of the PHF; patients who require hospitalization for acute mental illness now need to be hospitalized out-of- county (i.e., “privatized”). SCMH does serve as the managed care provider and pre-authorizer for Medi-Cal beneficiaries in Shasta County. This was confirmed by the SCMH Director (on two occasions), Deputy Director, and by multiple psychiatrists during the investigation; the Director of the NVMA concurred during a public forum held by the BOS in April 2005.
R5:
The Grand Jury recommends the SCMH Director improve lines of communication to ensure that SCMH policies affecting the medical community and other public agencies are uniform and consistent. We encourage SCMH to continue to improve access to its crisis intervention teams to reduce emergency room transfer delays. Moreover, to improve the continuity of patient care, we suggest that SCMH expedite the transfer of medical information (history, diagnosis and prescriptions) along with patients requiring out-of-county care. Conversely, SCMH should demand that discharge summaries accompany its patients returning from out-of-county facilities. Additionally, 6 the Grand Jury discourages the indiscriminate delegation of 5150 authority by the SCMH Director. Response from the SCMH Director: SCMH concurs with the recommendation regarding communication with the medical community and out of county facilities. SCMH will promote collaborative efforts with the NVMA to provide education and training for area physicians regarding the treatment of psychiatric illness. As stated in Response No. 3, another solution to the local emergency department congestion and transfer time delays is the implementation of a coordinated case management system that will provide wraparound medical and behavioral healthcare, and psychosocial supports to a population identified as frequent utilizers of the Mental Health emergency response system. SCMH, in collaboration with North State counties, looks forward to the opening of the North Valley Behavioral Health and Sequoia Psychiatric Center PHF in Yuba City, both of which will exclusively treat our patients. This will greatly enhance the continuity of care and communication of critical patient care issues on admission and discharge for Shasta County patients. GJ Reply to the Response: The Grand Jury generally agrees with the response, however, the indiscriminate delegation of 5150 authority was not addressed.
R6:
SCMH should establish written cost-sharing policies with the County Jail, Juvenile Hall, Probation department and other agencies for inpatient care and transportation of their mentally impaired inmates or clients. SCMH should improve its service to county agencies affected by the PHF closure, e.g. attend to inmates at the Main Jail and Juvenile Hall. Response from the SCMH Director: The Shasta County Sheriff’s Department and Probation Department maintain a contract with Prison Health Services for the provision of health and mental health services in the jail and juvenile hall. This contract is comprehensive in scope and specifies the responsibility of the provider in the provision of all planned and urgent medical services, including psychiatry. The contract includes the responsibility of the provider for reimbursement of hospital services for inmates and wards in custody, but excludes the contact provider from responsibility for reimbursement for psychiatric hospitalization. As a result, there is a serious gap in coverage for jail inmates in custody and juvenile wards in custody. SCMH works cooperatively with jail and juvenile hall staff to address this gap on a case-by-case basis, following written protocols that were developed collaboratively between the Sheriff’s Department, Probation Department, and Mental Health. SCMH also provides the services of a psychologist in juvenile hall and SHIFT (Shasta Housing Intervention For Transition) Program services in the jail to assist Prison Health Services and the courts with inmate/ward mental health issues. GJ Reply to the Response: The above response is inadequate. It does not address transportation protocols and/or cost sharing between SCMH and incarceration facilities since the closure of the PHF. The problem of court ordered on-site psychiatric evaluations is also not addressed. Jail representatives were unable to produce written protocols for inmate evaluation and treatment.
R7:
The BOS and SCMH should closely monitor the costs (including all transportation costs) of out-of-county inpatient care. The Grand Jury offers the following options for reestablishing inpatient psychiatric services for which the County still holds State licensure: iReopen the 15-bed PHF at the previous site on Breslauer Way by deleting its Medicare designation and adopting strict admission criteria for adult inpatients. This would reduce the average daily cost of care by 50 percent (to $2 million per year) and also minimize patient safety issues. Medicare inpatients requiring hospitalization would be cared for at other facilities. iOpen a 15-bed basic PHF on Breslauer way as a combined adult/child inpatient facility by designating 10 beds for adults and five for children. iOpen a 15-bed basic PHF on Breslauer as the only north state child inpatient facility. Costs would be more manageable and there is a very low risk of associated physical co- morbidity in this age group. The BOS should obtain sufficient information to determine whether or not to renew the SCMH $1.3 million yearly contract for the Elpida Crisis Residential Center. Any option to reopen a PHF would necessitate either closing or relocating this center. The Grand jury recommends closure. In that event, inpatient psychiatric services could be funded using current SCMH revenues generated by increasing efficiency, reducing out-of-county inpatient care, substituting primary care practitioners for some psychiatrists and eliminating costly Medicare staffing. Moreover, additional funding may become available beginning in 2005/2006 through the Mental Health Services Act. The Grand Jury believes that County residents could, and should, have local access to both inpatient and outpatient mental health services. Inpatient child psychiatric services have been identified as woefully inadequate for decades and the Grand Jury invites Shasta County to take the initiative and establish a child/adolescent inpatient facility. A north state regional, multi-county proposal for Mental Health Services Act funds (perhaps orchestrated by the SCMH Director) could establish a geographically centered, acute care facility for children with mental impairment. Benefits of such a facility to the overall mental health of children include earlier recognition and treatment of impairment and an improved continuity of care. Enhanced case management, better social rehabilitative services, access to intensive family psychotherapy and recruitment of more child psychiatrists could result from a successful program. This is an opportune time for Shasta County to address the psychiatric needs of north state children. Response from the BOS: SCMH has submitted the planned budget to the Shasta County Administrative Office including projected expenditures and revenues for fiscal year 2005/2006. In this budget, the SCMH department does not recommend that it operate a staff a psychiatric health facility during fiscal year 2005/2006. The BOS concurs that an involuntary mental health acute care inpatient unit is needed in Shasta County but realizes that patient safety is of the utmost importance. In an effort to meet the medical needs of all patients, the delivery of mental health treatment services (involuntary or voluntary) should be integrated with emergency and primary health care. The County PHF was not licensed to provide emergency medical or primary health care services, therefore, reopening the facility is not viable. SCMH, in collaboration with the Shasta County Administrative Office and the North Valley Medical Association (NVMA), has facilitated contacts between interested providers of inpatient behavioral health services and the administrators of the local general hospitals. The goal of this collaboration is to integrate acute care psychiatry into mainstream primary health care so that those suffering from mental illness have the opportunity to receive treatment for all of their medical needs in an environment where they are not stigmatized or isolated form medical care. The BOS agrees that a regional approach to specialty psychiatric care is viable for target populations. An example of the potential in this area is the soon to open North Valley Behavioral and Sequoia Psychiatric Center PHF. SCMH has taken a strong leadership role in this 4-year effort and the SCMH Director sits on the steering committee that has been responsible for the planning and implementation of these facilities. Specifically regarding the viability of a regional facility for children, SCMH has promoted three regional options. The first option was the establishment of a regional locked community treatment facility, which was not supported at a regional level. The second option was the dedication of one of the new regional psychiatric facilities to children, which was also not regionally supported. The third option is the establishment of a regional interagency crisis assessment center for children. This option may be considered as a priority focus under the Mental Health Services Act. GJ Reply to the Response: The Grand Jury disagrees with the response. Adequate revenue exists for the reestablishment of a local, scaled-down (i.e., non-Medicare) PHF. Strict admission criteria would greatly reduce patient safety issues. The BOS talks of integrated care, but the SCMH Director’s responses to recommendations 2, 3 and 5 above, do little to promote integration with primary health care. The BOS response claims the County PHF is not licensed for emergency medical or primary health care and therefore, reopening it is not a viable option. The Grand Jury notes that while none of the State PHFs are licensed for emergency medical or primary health care services, they continue to provide acute psychiatric inpatient care. The Grand Jury further notes that the North Valley Behavioral and Sequoia Psychiatric Center, to which Shasta County sends inpatients for treatment, is not a full-service hospital providing integrated health care. Moreover, the BOS response does not address the recommended closure of the Elpida Crisis Center. The Grand Jury suggests that the BOS need only look as far as Butte County to consider a functioning non-Medicare designated PHF. The Butte County PHF exists because of support by both the general public and the Butte County Mental Health Director. The integration with mainstream medical care for their patients with co-morbidities is easily obtained because of a positive relationship with the medical community of that County.
R8:
Other inpatient psychiatric services could include: iThe reopening of inpatient services for Medicare patients at a local rehabilitation facility. iA truly collaborative effort between SCMH and the local medical community too begin laying the groundwork for an inpatient psychiatric unit in one of the local full-service hospitals. Response from the BOS: The Shasta County BOS concurs with the recommendation that a local inpatient facility should be pursued. This facility should have the capacity to treat patients flexibly, which is best done in a licensed general hospital. SCMH, in conjunction with the Shasta County Administrative Office, has facilitated contracts with three corporations that are providers of behavioral health services that would like to develop a local inpatient facility. At a recent presentation, one provider made it clear that the provision of behavioral health services in a licensed general hospital with more than 100 beds is financially viable and of economic benefit to the hospital. NVMA representatives have made it contact with this provider and will facilitate meetings in an effort to promote the proposal, gain support from local hospitals, and encourage community involvement in this potential opportunity. GJ Reply to the Response: The Grand Jury accepts the response and awaits the outcome of this potential effort. The SCMH department is working with the NVMA to facilitate contacts between interested psychiatric providers and local hospitals. The Grand Jury applauds this portion of the response, but as noted in our report, the establishment of a psychiatric unit in a local full-service hospital is a three-year process.
R10:
The Grand Jury suggests that the BOS pay a site visit to the County-contracted Elpida Crisis Residential Center and closely evaluate the benefits of the contract’s automatic renewal after fiscal year 2004/2005. Should Elpida remain open, the Grand Jury also recommends adoption of a formal lease between the County and Elpida’s private sponsor and establishment of an Elpida Policies and Procedures Manual. Response from the BOS: Representatives from the BOS, County Administrative Office, and Mental Health Advisory Board participated in a tour of the Elpida Crisis Residential Center on September 7, 2005, as recommended by the Grand jury. The Elpida crisis residential Center maintains a policy and procedures manual that addresses the areas required by State regulation. GJ Reply to the Response: The Grand Jury finds the response inadequate. Only two Supervisors participated in the Elpida tour and no evaluation of the benefit of extending the contract was made. The response did not address a lease between the County and Elpida’s private sponsor. The Grand Jury is still awaiting receipt of the Policy and Procedures Manual from Elpida.
R11:
The Grand Jury recommends the County BOS and SCMH consider both financial and staffing support of a proposed County Detoxification Center. This center would afford opportunity for an improved collaboration between SCMH and both the local medical community and city governments. Establishment of a detoxification center would reduce the congestion in local hospital emergency rooms. Mental Health Services Act (Proposition 63) funding could be an additional source of financial support. Response from the BOS: The BOS, SCMH, and the Shasta County Alcohol and Drug Programs (SCADP) are in complete support of expanding the social model detoxification program in Shasta County. This is consistent with the “Community Action Plan” developed by representatives of Mercy Medical Center, Shasta Regional Medical Center, Shasta Community Health Center, the Good News Rescue Mission, SCMH, and the SCADP. A memorandum of understanding (MOU) has been developed by SCADP and circulated to the participants and other recommended collaborative partners. To date, only the City of Shasta Lake and the Shasta County Administrative Office have responded with support. The role of the Mental Health Services Act (Proposition 63) funding in this service expansion will be determined once the State Department of Mental Health guidelines for application for funding have been finalized and distributed. Additionally, the input received from stakeholders at more than 30 State required focus groups, conducted by SCMH, must be considered when prioritizing areas of need for mental health services expansion. This process targeted for completion in October to allow for a timely submission to the State Department of Mental Health. GJ Reply to the Response: The Grand Jury is satisfied with the response. We are also discouraged that only two collaborators have committed financially to a project that received unanimous support from all interviewees.
R12:
The Grand Jury recommends that County and City Government guarantee public safety at all times by ensuring law enforcement personnel attend to 11 5150-designated patients while they are treated in, and until they are transferred from, local “unlocked” emergency rooms. Response from the BOS: The process for transfer of law enforcement 5150 detentions is governed by an interagency agreement developed by local law enforcement agencies in collaboration with representatives of SCMH, Shasta regional Medical Center, Mercy Medical Center, and Mayers Memorial Hospital District. Less than half of the calls to the emergency departments are the result of this process. More than half of the calls for SCMH crisis response are for patients who have presented to the emergency departments without law enforcement involvement. Thus, law enforcement personnel are not present in these cases while the emergency department examines the patient to determine if an emergency medical condition exists consistent with the federal requirements under the Emergency Medical Treatment and Labor Act. In these cases, SCMH determines the legal status of the patient if the emergency department physician decides that transfer or discharge to a specialty psychiatric facility is necessary. Response from the City of Redding: The Grand Jury recommendation requires further analysis. The Police Chief cannot guarantee that law enforcement personnel attend to 5150-designated patients while they are “treated in, and until they are transferred from, local unlocked emergency rooms.” It would mean that police officers would need to be diverted from our neighborhoods and businesses to attend to individuals who should be at a detoxification center or at a mental health facility for as much as 24 to 30 hours. Currently, police officers remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to themselves or anyone else. Since the closure of the County PHF, police time necessary to handle these calls has already increased 66%. Remaining at the hospital to await transportation would further tax resources by doubling the average amount of time spent by police with each patient. We agree with the hospitals that the solution is not more police officers, but rather more and better health care. Specifically, patients need to be evaluated much quicker as to the cause of their illness (drugs, alcohol, or mental health) and the patients need to be transferred, where appropriate to a detoxification center or a mental health facility. Having patients come to a hospital emergency room, waiting much too long for evaluation, and having a police officer sit in an emergency room and spend time with that patient for hours and hours is a poor use of the public’s limited resources and is not a solution to the premature closure of the County’s Mental Health Facility. Response from the City of Anderson (received August 18, 2005): Just like the Grand Jury, the City of Anderson, as well as our Chief of Police, are very concerned about public safety. As such, we cannot guarantee that Anderson Police Department (APD) officers can attend to 5150-designated patients “until they are transferred from local ‘unlocked’ emergency rooms.” To meet this recommendation, police officers would need top be diverted from our neighborhoods and businesses to attend to individuals who 12 should be at a detoxification center or at a mental health facility for a minimum of several hours and/or as much as twenty-four to thirty hours. Diverting officers from their patrol duties would not guarantee public safety, but instead would decrease public safety in our own neighborhoods by reducing the number of officers available for law enforcement. Typically, ADP deploys two to three officers on each twelve-hour shift. These officers’s primary responsibility is the safety and security of the Community of Anderson. Currently, when an arrest is made, or a 5150-designated patient is taken into civil arrest custody, the shift coverage is reduced to two officers, and too often to just one officer, remaining in the City. Obviously this represents not only an “officer safety” issue but a “community safety” issue as well. Currently, an ADP officer will remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to himself or herself or anyone else. Since the premature closure of the Shasta County Mental Psychiatric Facility, without adequate planning, the amount of time a police officer must spend at the hospitals handling 5150-designated patient calls has already increased. Remaining at the hospital to await transfer, as recommended by the Grand Jury, would further tax APD’s resources, typically doubling the average amount of time spent by the officer with each 5150-designated patient. The Anderson City Council appreciates the opportunity to respond to Grand Jury Recommendation Number 12 and hopes that our response is helpful. Response from the City of Shasta Lake (received July 28, 2005): The City of Shasta Lake agrees with the recommendation. Law enforcement services for the City of Shasta Lake are provided by the Shasta County Sheriff’s Department. The Sheriff has provided these services since the City’s incorporation in 1993. It is currently the policy of the Shasta County Sheriff’s department to provide law enforcement personnel to attend 5150-designated persons while they are treated in, and until they are transferred from local unlocked emergency rooms. GJ Reply to the Responses: The Grand Jury accepts the responses from the representatives of law enforcement in the County. We acknowledge the extra time and cost of attending to 5150-designated patients. We remain concerned that persons, who by definition are a risk to themselves or others, even when stabilized, are left unattended in area emergency rooms. A potential for harm within the hospital setting, or after a 5150 designee decides to leave against medical advice, remains a public safety issue.
R13:
The MHAB needs broader community representation. Private physician, local hospital and clinic, and law enforcement inclusion would strengthen the MHAB role as the community advocate for mental health issues. The Grand Jury encourages the BOS to improve the MHAB composition and strongly urges the MHAB to carefully review all major contracts entered into by SCMH. Response from the BOS: the BOS concurs with the Grand Jury’s recommendation regarding the expansion of community representation on the Mental Health Board. The Chairperson will work with the Mental Health Board Membership Committee to recruit a broader cross-section of community members. The MHAB will continue to review the State Department of Mental Health Performance Contract, which governs aspects of the operations of the SCMH Department before it is submitted to the BOS for approval. GJ Reply to the Response: The Grand Jury is satisfied with the response and again encourages MHAB input on all major contracts entered into by SCMH.
R14:
Citizens of Shasta County can take advantage of a new source of state funding for expanded mental health services through the Mental Health Services Act. Similar to new library construction funding a few years ago, this Act awards state tax revenues to individual or joint county proposals for services based on the merits of the plans submitted. Shasta County citizens rallied impressively to support the library and the Grand Jury strongly recommends the BOS encourage a similar community effort. This is an excellent opportunity for increasing access to local services that are both desperately needed and chronically under funded. Mental health services should be prioritized through the public input sessions sponsored by SCMH. The BOS and MHAB should incorporate this community input into any proposal being submitted. Response from the BOS: The BOS concurs with the Grand Jury recommendations regarding the Mental Health Services Act. GJ Reply to the Response: The Grand Jury appreciates the response. The Grand Jury is concerned that a broad community effort to mobilize for real change in local mental health service delivery is not a priority. The BOS consistently ignores community needs for access to local inpatient care by allowing SCMH to export inpatients to out-of-county facilities. While purporting to support the active integration of mental illness into mainstream medicine, BOS policies and SCMH decisions continue to impede this integration. If the BOS, SCMH and area providers cannot unite to address this problem, it is unlikely that cohesive community support will follow.
R15:
The BOS should not rely entirely on staff recommendations when considering future funding and direction of mental health policy in Shasta County. Assigning large, long-term, mo-bid contracts for untried services (Elpida) and closing the super PHF against the recommendations of the MHAB and a citizen’s Community Committee do not represent the best interests of County residents. Since the prior BOS (with the exception of one member) felt economic considerations superceded community recommendations to maintain an inpatient facility, the Grand jury encourages the current BOS (with two new members) to reexamine the issue. From the data presented in this 14 report, the Grand Jury recommends the BOS reconsider the economic factors that led to the decision to close the PHF. We fully appreciate the patient safety issues of the inpatient facility as it was configured prior to its closure. However, our investigation indicates that reopening a basic PHF (non-Medicare) with strict admission criteria is an economically viable and safe alternative to having no local locked inpatient facility at all. Establishing appropriate and affordable local inpatient hospital services would improve patient access ands care and alleviate the problems generated by the closure of the PHF. In conclusion, the Shasta county Grand jury asks the BOS to examine all the facts and govern for its constituents, and not for what benefits SCMH. Response from the BOS: The BOS does not rely solely on the recommendations of staff when considering funding or policy changes. The Board follows an extensive process of review to include a departmental staff report, County Administrative Office review and concurrence, County Counsel review, and Risk Management review. In addition, the Board receives and considers constituent feedback, including Advisory Board input, and public input regarding all Shasta County issues. The BOS voted 4-1 to close the PHF after considering all of the information and several factors including patient safety due to the lack of emergency medical care and the subsequent exposure to litigation. Continued operation of the PHF would require significant funding reductions in other areas of the Mental Health Department. Mental Health Outpatient services would have to be eliminated to ensure the ongoing financial viability of the inpatient unit. Discontinuing outpatient treatment programs would impact a larger population than the closure of the PHF. The loss of outpatient treatment services would impact approximately 87 percent of the total SCMH patient population receiving preventative services, case management, therapy, life management skills, medical management skills, counseling, and other specialty services that minimize or eliminate the need for emergency mental health treatment. Without outpatient treatment the need for emergency mental health treatment services would increase exponentially and exceed the capacity of the PHF. The legal, social, and fiscal impact on law enforcement, social support agencies, and the community in general would be significant. The Grand jury recommendation states that the Elpida contract was a large, long-term, no-bid contract for untried services. The initial term for the Elpida Crisis Residential contract commenced July 1, 2004, and ended on June 30, 2005. The contract was renewed for the same term length for fiscal year 2005-2006 on July 1, 2005. The Elpida Crisis Recovery Center is a subsidiary organization of Crestwood behavioral Health, Inc. Shasta County has had many contractual agreements with Crestwood for similar residential psychiatric services. The Elpida contract was approved by the Board in an amount not to exceed $1,124,200. This amount represents a cost savings for inpatient services that were provided at the PHF. GJ Reply to the Response: The Grand Jury disagrees with the response. With the exception of this final recommendation, all the responses received from the BOS 15 appear to have been provided solely by SCMH; they are taken almost verbatim from a set of responses received earlier from the SCMH Director. This is an indication of a continued over-reliance on staff recommendations. We feel compelled to point out that the Elpida Center is not licensed as a locked inpatient acute care facility (i.e., a PHF) and is not similar to other Shasta County- Crestwood psychiatric ventures. And although some patients are transferred from local emergency rooms directly to Elpida, it remains our contention that expenditures for this facility do little to address the need of County residents for acute inpatient treatment. The Grand Jury remains convinced that developing our own inpatient services is preferable to renting them. We contend that reopening a basic PHF is economically viable, as the yearly cost for a similar facility in Butte County is around $2 million. This represents less than 10 percent of the total SCMH budget, and less than the County is now spending for Elpida and out-of-county inpatient facilities. It is our belief that this will not impact the delivery of outpatient mental health services as described in the response. Conclusion: Prior to, and since the release of our report, public interest in the delivery of mental health services to County residents continues to make news. In April 2005, the BOS held a workshop on mental health issues and listened to patient and provider complaints. In May, the BOS, in conjunction with local hospitals and the Shasta Community Health Center, agreed to seek funding for an outside consultant to review the operations of SCMH. The Grand Jury commends the review and hopes its findings will lead to an improved delivery of care. In July, SCMH psychiatrists finally applied for privileges at one local hospital, but not at the other. A claimed “lack of collegiality” at the hospitals was offered as the reason SCMH physicians had not previously applied for privileges. An unfriendly response is not a reason to seek or deny privileges, nor has it prevented other specialists from attempting to do so. This slow pace of psychiatrist integration into general medicine, and a similar disinterest of the medical community to “buy-in” to the public delivery of mental health care provided by SCMH, remains a significant obstacle to further progress. For example, the declining interest in establishing a joint-partnership, community- sponsored, detoxification center underscores the level of mistrust between providers, SCMH and local government. The integration of mental illness into mainstream medicine cannot occur without willing and effective leadership from all sides. Over the summer months, anecdotal stories from citizens about their inability to access care at SCMH continued to be heard by the BOS. Claims by SCMH administrators that “payer source” is not a factor in the decision to treat patients have been contradicted by both community physicians and families. The Grand 16 Jury remains concerned that there will be no resolution of SCMH bureaucracy and, therefore, gaps in coverage will continue. On a positive note, SCMH will hold a Mental Health Services Act (Proposition 63) public hearing and release its community action plan for funding in October. The Grand Jury applauds the effort by SCMH in soliciting broad community involvement over the past year and looks forward to the presentation of the plan. A major goal of our report was to expand the community discussion about mental health. We believe this has been accomplished. However, discussion is only the first step. Productive action by local government is still lacking. Even with re-opening an inpatient facility, the poor communication between SCMH and the medical community, the ongoing problems with patient access, and an overly bureaucratic mental health department, continue to stymie progress. Report No. 3: Redding Land Purchases The Grand Jury reported on the increasing number of land purchases by the City of Redding, specifically the purchase of an 82-acre vacant parcel along Interstate 5. The parcel, ostensibly purchased as a buffer zone to the City’s southern boundary, is situated mostly in a flood plain and lies outside the city limits. The $1.5 million purchase was funded by a loan to the City’s general fund from the Redding Electric Utility (REU) reserve fund. The report also focused on the use of Redevelopment funding for the purchase of two other properties. The City of Redding responded to four recommendations by letter submitted to the presiding judge of the Superior Court by the Mayor of Redding on July 20, 2005.
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Findings & Recommendations
19 findings
F1:
The Grand Jury had lunch prepared by the cadets. The kitchen/dining hall, barracks, workshops and campgrounds were clean and well maintained. During the tour, the Grand Jury looked for signs of graffiti; none was found.
F2:
The BOC Inspection Report of June 2003 states that funds available for staffing are only enough to license 45 of the possible 60-bed capacity.
F3:
The average number of cadets at the camp is 42 and the average length of their stay is 90-120 days.
F4:
Vocational programs such as learning work skills in construction, computer assembly and repair and food preparation are available. The cadets gain practical experience while working on various projects in the community. These team activities help to promote a good work ethic and responsibility. The cadets are also provided the opportunity to obtain their General Education Diploma. School attendance is required three days a week, six hours per day. The following special programs are available to the cadets for readjustment into the community: • Anger Management • Gang Awareness • Construction Trades • Job Skills • Culinary Arts • Leadership Skills • Domestic Violence • Life Skills • Drug and Alcohol • Victim Awareness • First-Aid and CPR
F5:
One of the three Crystal Creek Regional Boys’ Camp classrooms is not being used due to lack of funding for a teacher and an aide. The position of Mental Health Counselor is unfilled, due to lack of funding. Other counties pay Shasta County for the cadets that they assign to the camp. The rate varies from $58 to $76 per day with 65% of the counties paying the higher rate. To meet the budgetary goals, the camp needs an average of 26 cadets per day from other counties. At the time of the Grand Jury visit the number of cadets from other counties was 21, which has been the average since June
F6:
The District continues to maintain accounts that are significantly past due. In the fiscal year 2001/2002 annual audit of the District, it was recommended that old accounts be aggressively collected or “written off” as bad debt. The District has not implemented this recommendation.
F7:
In the 2000/2001, 2001/2002 and 2002/2003 annual audits, the auditing firm noted that the District’s bond agreements require that certain amounts be maintained by the District as reserve or restricted cash to meet current interest and principal requirements. The audit report reviewed by the Grand Jury recommended accounts for note funds, reserve funds, operation and maintenance funds, and a surplus fund. The District has not implemented this
F8:
During the interviews, employees and board members told the Grand Jury that payroll advances were seldom used. However, the auditing firm provided a ledger prepared by the District showing 39 payroll advances during fiscal year 2002/2003. In all of the annual audits reviewed by the Grand Jury, the auditing firm recommended discontinuing the practice of payroll advances. The District has not implemented this recommendation.
F9:
The District has no formal policy for purchasing those items needed for the District’s use. The District maintains several open charge accounts at various local businesses.
F10:
The District uses two cellular phones for general communication. The Grand Jury reviewed three months of cellular phone bills and found that they were in excess of $300 per month.
F11:
The District has no long-term Master Water Plan. A Master Water Plan is an engineering study of the water system that includes preliminary plans with scheduling and cost estimates for future system maintenance, repairs, equipment replacements, and major capital improvements. A plan helps ensure that the community’s present and future water quality and supply needs are met in an efficient and economical matter. This practice allows the District to properly prepare and budget for its future needs.
F12:
The District does not maintain an accurate subsidiary ledger of customer deposits. This list shows customer deposits since the 1970’s. All annual audits reviewed by the Grand Jury recommended that the District update the customer deposit ledger. The District has not implemented this recommendation.
F13:
The District does not maintain an accurate subsidiary ledger of inventory and does not have a process in place for an annual inventory. The fiscal year 2002/2003 audit recommended the District keep a year-end fiscal inventory and maintains an inventory subsidiary ledger. The District has not implemented this
F14:
The District has had to sell off a portion of its investments each year to service the District’s operating expenses. This is depleting the cash balance of the District. The District does not generate sufficient revenue to cover debt service on the 1973 and 1979 bonds and the 1973 Drought Relief loan. The debt service for fiscal year 2003/2004 is $42,782.00. Annual audits reviewed by the Grand Jury recommended that the District take the steps necessary to generate sufficient revenue to cover debt service and operating expenses without depleting cash reserves. The District increased water and sewer rates by 15% in August 2001 and by 20% in November 2003. The former District Manager and the Auditors stated that the rate increases would be insufficient to cover the District’s expenses.
F15:
For the fiscal years ended June 30, 2001, 2002 and 2003, the District had an excess of expenses over revenue of $84,912, $70,034 and $82,041 respectively.
F16:
Chlorine gas supplies are not adequately secured at the water treatment facility to prevent theft, vandalism or terrorist acts.
F17:
In 2003, the SCSD Board and Water Department employees participated in only one of many available seminars, workshops, conferences and professional organization meetings.
F18:
The last Insurance Services Office (ISO) report was issued November 1, 1985. SCSD received a 57.93% credit, earning a Public Protection Class 5 rating. Premiums charged to homeowners and businesses for fire protection insurance are lower if the credit is higher (60-100%).
F19:
The SCSD Board approved and adopted on November 20, 2003 a Master Water Plan prepared by Pace Civil Inc. The plan gives the SCSD Board direction on providing water service to the district’s customers for the next 20 years.
Additional Recommendations
14
Not linked to specific findings.
R1:
The City Council should not derail well designed Infill and Planned Developments. Response: Concur, if they meet the General Plan and other development policies as determined by the public’s elected representatives who are selected to make these decisions. The Grand Jury’s finding on this matter (No. 6) has substantial factual errors. The City Council determined that the project was not consistent with the General Plan. The design of the project contained aspects that did not comply with the General Plan policy. GJ Reply to the Response: The Grand Jury finds the City Council’s response unacceptable. The Grand Jury determined that the project was consistent with the General Plan. Furthermore, if “…the project was not consistent with the General Plan,” as stated above, then it should not have been approved by the Planning Department in the first place.
R2:
The Planning Department should attempt to expedite the permit approval process. The City’s Ombudsman report on recommended process changes should continue to be implemented. Response: Grand Jury Finding No. 9 states that “the City’s Ombudsman Report on Recommended Process Changes was presented to the City Council for consideration on October 25, 2004. …Some of these recommendations are being implemented by the City’s Development Services Department.” In fact, all of these measures are being implemented with the exception of the permit tracking system. The tracking system is extremely expensive, which is why it has taken longer than the other points mentioned in the Grand Jury’s findings. However, the City Council will be discussing this issue as the City looks at planning and engineering fee increases in the next few months. GJ Reply to the Response: The Grand Jury finds the response acceptable and looks forward to the implementation of the permit tracking system.
R3:
Political influence should not override sound planning decisions. Response: Concur. Grand Jury Finding No. 8 states that, “strong political influence was exerted on the Planning Commission and City Council to disapprove this project.” This is obviously a statement of opinion. It would be equally valid to say that strong political pressure was exerted on the Planning Commission and City Council to approve the 2 project. Concerns for and against projects will very likely continue as the City entertains more infill projects. GJ Reply to the Response: The Grand Jury finds the response acceptable. However, it remains our “opinion” that the front-row presence of McConnell Foundation executives at the City Council meeting regarding opposition to this project represented undue “strong political influence” against the project’s approval. Report No. 2: Haste Makes Waste In a lengthy report, the 2004/2005 Grand Jury investigated the closure of the Shasta County Psychiatric Hospital Facility (PHF) and its impact on inpatient care of the acutely mentally ill. The overall operation of the Shasta County Mental Health Department (SCMH) was also investigated. The required response from the Shasta County Board of Supervisors (BOS) was sent to the presiding judge of the superior court on September 27, 2005. The Director of SCMH was also invited to respond to certain recommendations; the response was received on August 29, 2005.
R4:
The Shasta County BOS should consider privatizing, in part or in total, the delivery of mental health services to the citizens of the county. With proper oversight, this would offer a more efficient overall operation. Assurances that all patients requiring treatment actually receive treatment would be necessary. The Grand Jury feels an extensive and well-planned transition program, with input from the general public and all providers of mental healthcare delivery, must precede any transfer from public to private operation. Response from the BOS: Currently 54 percent of the SCMH budget is devoted to contract services, and this has consistently increased over the past 2-3 fiscal years. As a result, SCMH is more than half “privatized.” With each contract for services entered into by the BOS, SCMH must assure that services are delivered in accordance with State Department of Mental Health requirements, which govern target population, service delivery, and the receipt of State and federal funds. SCMH provides mental health services to the residents of Shasta County in compliance with three State Department of Mental Health contracts. These contracts include very specific terms and conditions and are renewed annually with the approval of the BOS. (A one-page description of the contracts accompanied the response). The Grand Jury notes in its findings a number of perceptions regarding the role of SCMH in the delivery and authorization of inpatient mental health services that are not consistent with this contract and SCMH’s practice. The first and most important misperception is related to access to psychiatric hospitalization for all Medi-Cal eligible Shasta county residents. There are no pre-authorization requirements for emergency admissions to psychiatric inpatient hospitals for Shasta County Medi-Cal beneficiaries. SCMH provides post-admission review of written Treatment Authorization Requests submitted by hospitals as required by the State prior to payment by EDS (Electronic Data Systems). Since SCMH is no longer a provider of psychiatric hospital services, independent practitioners affiliated with the private treating facilities now make the determination of the patient’s admission and continued stay. GJ Reply to the Response: The Grand Jury disagrees with the response. The intent of the recommendation was to consider privatizing the entire mental health delivery system in Shasta County, including its administration. The privatization discussed by the BOS was, in part, necessitated by the closure of the PHF; patients who require hospitalization for acute mental illness now need to be hospitalized out-of- county (i.e., “privatized”). SCMH does serve as the managed care provider and pre-authorizer for Medi-Cal beneficiaries in Shasta County. This was confirmed by the SCMH Director (on two occasions), Deputy Director, and by multiple psychiatrists during the investigation; the Director of the NVMA concurred during a public forum held by the BOS in April 2005.
R5:
The Grand Jury recommends the SCMH Director improve lines of communication to ensure that SCMH policies affecting the medical community and other public agencies are uniform and consistent. We encourage SCMH to continue to improve access to its crisis intervention teams to reduce emergency room transfer delays. Moreover, to improve the continuity of patient care, we suggest that SCMH expedite the transfer of medical information (history, diagnosis and prescriptions) along with patients requiring out-of-county care. Conversely, SCMH should demand that discharge summaries accompany its patients returning from out-of-county facilities. Additionally, 6 the Grand Jury discourages the indiscriminate delegation of 5150 authority by the SCMH Director. Response from the SCMH Director: SCMH concurs with the recommendation regarding communication with the medical community and out of county facilities. SCMH will promote collaborative efforts with the NVMA to provide education and training for area physicians regarding the treatment of psychiatric illness. As stated in Response No. 3, another solution to the local emergency department congestion and transfer time delays is the implementation of a coordinated case management system that will provide wraparound medical and behavioral healthcare, and psychosocial supports to a population identified as frequent utilizers of the Mental Health emergency response system. SCMH, in collaboration with North State counties, looks forward to the opening of the North Valley Behavioral Health and Sequoia Psychiatric Center PHF in Yuba City, both of which will exclusively treat our patients. This will greatly enhance the continuity of care and communication of critical patient care issues on admission and discharge for Shasta County patients. GJ Reply to the Response: The Grand Jury generally agrees with the response, however, the indiscriminate delegation of 5150 authority was not addressed.
R6:
SCMH should establish written cost-sharing policies with the County Jail, Juvenile Hall, Probation department and other agencies for inpatient care and transportation of their mentally impaired inmates or clients. SCMH should improve its service to county agencies affected by the PHF closure, e.g. attend to inmates at the Main Jail and Juvenile Hall. Response from the SCMH Director: The Shasta County Sheriff’s Department and Probation Department maintain a contract with Prison Health Services for the provision of health and mental health services in the jail and juvenile hall. This contract is comprehensive in scope and specifies the responsibility of the provider in the provision of all planned and urgent medical services, including psychiatry. The contract includes the responsibility of the provider for reimbursement of hospital services for inmates and wards in custody, but excludes the contact provider from responsibility for reimbursement for psychiatric hospitalization. As a result, there is a serious gap in coverage for jail inmates in custody and juvenile wards in custody. SCMH works cooperatively with jail and juvenile hall staff to address this gap on a case-by-case basis, following written protocols that were developed collaboratively between the Sheriff’s Department, Probation Department, and Mental Health. SCMH also provides the services of a psychologist in juvenile hall and SHIFT (Shasta Housing Intervention For Transition) Program services in the jail to assist Prison Health Services and the courts with inmate/ward mental health issues. GJ Reply to the Response: The above response is inadequate. It does not address transportation protocols and/or cost sharing between SCMH and incarceration facilities since the closure of the PHF. The problem of court ordered on-site psychiatric evaluations is also not addressed. Jail representatives were unable to produce written protocols for inmate evaluation and treatment.
R7:
The BOS and SCMH should closely monitor the costs (including all transportation costs) of out-of-county inpatient care. The Grand Jury offers the following options for reestablishing inpatient psychiatric services for which the County still holds State licensure: iReopen the 15-bed PHF at the previous site on Breslauer Way by deleting its Medicare designation and adopting strict admission criteria for adult inpatients. This would reduce the average daily cost of care by 50 percent (to $2 million per year) and also minimize patient safety issues. Medicare inpatients requiring hospitalization would be cared for at other facilities. iOpen a 15-bed basic PHF on Breslauer way as a combined adult/child inpatient facility by designating 10 beds for adults and five for children. iOpen a 15-bed basic PHF on Breslauer as the only north state child inpatient facility. Costs would be more manageable and there is a very low risk of associated physical co- morbidity in this age group. The BOS should obtain sufficient information to determine whether or not to renew the SCMH $1.3 million yearly contract for the Elpida Crisis Residential Center. Any option to reopen a PHF would necessitate either closing or relocating this center. The Grand jury recommends closure. In that event, inpatient psychiatric services could be funded using current SCMH revenues generated by increasing efficiency, reducing out-of-county inpatient care, substituting primary care practitioners for some psychiatrists and eliminating costly Medicare staffing. Moreover, additional funding may become available beginning in 2005/2006 through the Mental Health Services Act. The Grand Jury believes that County residents could, and should, have local access to both inpatient and outpatient mental health services. Inpatient child psychiatric services have been identified as woefully inadequate for decades and the Grand Jury invites Shasta County to take the initiative and establish a child/adolescent inpatient facility. A north state regional, multi-county proposal for Mental Health Services Act funds (perhaps orchestrated by the SCMH Director) could establish a geographically centered, acute care facility for children with mental impairment. Benefits of such a facility to the overall mental health of children include earlier recognition and treatment of impairment and an improved continuity of care. Enhanced case management, better social rehabilitative services, access to intensive family psychotherapy and recruitment of more child psychiatrists could result from a successful program. This is an opportune time for Shasta County to address the psychiatric needs of north state children. Response from the BOS: SCMH has submitted the planned budget to the Shasta County Administrative Office including projected expenditures and revenues for fiscal year 2005/2006. In this budget, the SCMH department does not recommend that it operate a staff a psychiatric health facility during fiscal year 2005/2006. The BOS concurs that an involuntary mental health acute care inpatient unit is needed in Shasta County but realizes that patient safety is of the utmost importance. In an effort to meet the medical needs of all patients, the delivery of mental health treatment services (involuntary or voluntary) should be integrated with emergency and primary health care. The County PHF was not licensed to provide emergency medical or primary health care services, therefore, reopening the facility is not viable. SCMH, in collaboration with the Shasta County Administrative Office and the North Valley Medical Association (NVMA), has facilitated contacts between interested providers of inpatient behavioral health services and the administrators of the local general hospitals. The goal of this collaboration is to integrate acute care psychiatry into mainstream primary health care so that those suffering from mental illness have the opportunity to receive treatment for all of their medical needs in an environment where they are not stigmatized or isolated form medical care. The BOS agrees that a regional approach to specialty psychiatric care is viable for target populations. An example of the potential in this area is the soon to open North Valley Behavioral and Sequoia Psychiatric Center PHF. SCMH has taken a strong leadership role in this 4-year effort and the SCMH Director sits on the steering committee that has been responsible for the planning and implementation of these facilities. Specifically regarding the viability of a regional facility for children, SCMH has promoted three regional options. The first option was the establishment of a regional locked community treatment facility, which was not supported at a regional level. The second option was the dedication of one of the new regional psychiatric facilities to children, which was also not regionally supported. The third option is the establishment of a regional interagency crisis assessment center for children. This option may be considered as a priority focus under the Mental Health Services Act. GJ Reply to the Response: The Grand Jury disagrees with the response. Adequate revenue exists for the reestablishment of a local, scaled-down (i.e., non-Medicare) PHF. Strict admission criteria would greatly reduce patient safety issues. The BOS talks of integrated care, but the SCMH Director’s responses to recommendations 2, 3 and 5 above, do little to promote integration with primary health care. The BOS response claims the County PHF is not licensed for emergency medical or primary health care and therefore, reopening it is not a viable option. The Grand Jury notes that while none of the State PHFs are licensed for emergency medical or primary health care services, they continue to provide acute psychiatric inpatient care. The Grand Jury further notes that the North Valley Behavioral and Sequoia Psychiatric Center, to which Shasta County sends inpatients for treatment, is not a full-service hospital providing integrated health care. Moreover, the BOS response does not address the recommended closure of the Elpida Crisis Center. The Grand Jury suggests that the BOS need only look as far as Butte County to consider a functioning non-Medicare designated PHF. The Butte County PHF exists because of support by both the general public and the Butte County Mental Health Director. The integration with mainstream medical care for their patients with co-morbidities is easily obtained because of a positive relationship with the medical community of that County.
R8:
Other inpatient psychiatric services could include: iThe reopening of inpatient services for Medicare patients at a local rehabilitation facility. iA truly collaborative effort between SCMH and the local medical community too begin laying the groundwork for an inpatient psychiatric unit in one of the local full-service hospitals. Response from the BOS: The Shasta County BOS concurs with the recommendation that a local inpatient facility should be pursued. This facility should have the capacity to treat patients flexibly, which is best done in a licensed general hospital. SCMH, in conjunction with the Shasta County Administrative Office, has facilitated contracts with three corporations that are providers of behavioral health services that would like to develop a local inpatient facility. At a recent presentation, one provider made it clear that the provision of behavioral health services in a licensed general hospital with more than 100 beds is financially viable and of economic benefit to the hospital. NVMA representatives have made it contact with this provider and will facilitate meetings in an effort to promote the proposal, gain support from local hospitals, and encourage community involvement in this potential opportunity. GJ Reply to the Response: The Grand Jury accepts the response and awaits the outcome of this potential effort. The SCMH department is working with the NVMA to facilitate contacts between interested psychiatric providers and local hospitals. The Grand Jury applauds this portion of the response, but as noted in our report, the establishment of a psychiatric unit in a local full-service hospital is a three-year process.
R10:
The Grand Jury suggests that the BOS pay a site visit to the County-contracted Elpida Crisis Residential Center and closely evaluate the benefits of the contract’s automatic renewal after fiscal year 2004/2005. Should Elpida remain open, the Grand Jury also recommends adoption of a formal lease between the County and Elpida’s private sponsor and establishment of an Elpida Policies and Procedures Manual. Response from the BOS: Representatives from the BOS, County Administrative Office, and Mental Health Advisory Board participated in a tour of the Elpida Crisis Residential Center on September 7, 2005, as recommended by the Grand jury. The Elpida crisis residential Center maintains a policy and procedures manual that addresses the areas required by State regulation. GJ Reply to the Response: The Grand Jury finds the response inadequate. Only two Supervisors participated in the Elpida tour and no evaluation of the benefit of extending the contract was made. The response did not address a lease between the County and Elpida’s private sponsor. The Grand Jury is still awaiting receipt of the Policy and Procedures Manual from Elpida.
R11:
The Grand Jury recommends the County BOS and SCMH consider both financial and staffing support of a proposed County Detoxification Center. This center would afford opportunity for an improved collaboration between SCMH and both the local medical community and city governments. Establishment of a detoxification center would reduce the congestion in local hospital emergency rooms. Mental Health Services Act (Proposition 63) funding could be an additional source of financial support. Response from the BOS: The BOS, SCMH, and the Shasta County Alcohol and Drug Programs (SCADP) are in complete support of expanding the social model detoxification program in Shasta County. This is consistent with the “Community Action Plan” developed by representatives of Mercy Medical Center, Shasta Regional Medical Center, Shasta Community Health Center, the Good News Rescue Mission, SCMH, and the SCADP. A memorandum of understanding (MOU) has been developed by SCADP and circulated to the participants and other recommended collaborative partners. To date, only the City of Shasta Lake and the Shasta County Administrative Office have responded with support. The role of the Mental Health Services Act (Proposition 63) funding in this service expansion will be determined once the State Department of Mental Health guidelines for application for funding have been finalized and distributed. Additionally, the input received from stakeholders at more than 30 State required focus groups, conducted by SCMH, must be considered when prioritizing areas of need for mental health services expansion. This process targeted for completion in October to allow for a timely submission to the State Department of Mental Health. GJ Reply to the Response: The Grand Jury is satisfied with the response. We are also discouraged that only two collaborators have committed financially to a project that received unanimous support from all interviewees.
R12:
The Grand Jury recommends that County and City Government guarantee public safety at all times by ensuring law enforcement personnel attend to 11 5150-designated patients while they are treated in, and until they are transferred from, local “unlocked” emergency rooms. Response from the BOS: The process for transfer of law enforcement 5150 detentions is governed by an interagency agreement developed by local law enforcement agencies in collaboration with representatives of SCMH, Shasta regional Medical Center, Mercy Medical Center, and Mayers Memorial Hospital District. Less than half of the calls to the emergency departments are the result of this process. More than half of the calls for SCMH crisis response are for patients who have presented to the emergency departments without law enforcement involvement. Thus, law enforcement personnel are not present in these cases while the emergency department examines the patient to determine if an emergency medical condition exists consistent with the federal requirements under the Emergency Medical Treatment and Labor Act. In these cases, SCMH determines the legal status of the patient if the emergency department physician decides that transfer or discharge to a specialty psychiatric facility is necessary. Response from the City of Redding: The Grand Jury recommendation requires further analysis. The Police Chief cannot guarantee that law enforcement personnel attend to 5150-designated patients while they are “treated in, and until they are transferred from, local unlocked emergency rooms.” It would mean that police officers would need to be diverted from our neighborhoods and businesses to attend to individuals who should be at a detoxification center or at a mental health facility for as much as 24 to 30 hours. Currently, police officers remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to themselves or anyone else. Since the closure of the County PHF, police time necessary to handle these calls has already increased 66%. Remaining at the hospital to await transportation would further tax resources by doubling the average amount of time spent by police with each patient. We agree with the hospitals that the solution is not more police officers, but rather more and better health care. Specifically, patients need to be evaluated much quicker as to the cause of their illness (drugs, alcohol, or mental health) and the patients need to be transferred, where appropriate to a detoxification center or a mental health facility. Having patients come to a hospital emergency room, waiting much too long for evaluation, and having a police officer sit in an emergency room and spend time with that patient for hours and hours is a poor use of the public’s limited resources and is not a solution to the premature closure of the County’s Mental Health Facility. Response from the City of Anderson (received August 18, 2005): Just like the Grand Jury, the City of Anderson, as well as our Chief of Police, are very concerned about public safety. As such, we cannot guarantee that Anderson Police Department (APD) officers can attend to 5150-designated patients “until they are transferred from local ‘unlocked’ emergency rooms.” To meet this recommendation, police officers would need top be diverted from our neighborhoods and businesses to attend to individuals who 12 should be at a detoxification center or at a mental health facility for a minimum of several hours and/or as much as twenty-four to thirty hours. Diverting officers from their patrol duties would not guarantee public safety, but instead would decrease public safety in our own neighborhoods by reducing the number of officers available for law enforcement. Typically, ADP deploys two to three officers on each twelve-hour shift. These officers’s primary responsibility is the safety and security of the Community of Anderson. Currently, when an arrest is made, or a 5150-designated patient is taken into civil arrest custody, the shift coverage is reduced to two officers, and too often to just one officer, remaining in the City. Obviously this represents not only an “officer safety” issue but a “community safety” issue as well. Currently, an ADP officer will remain at the hospital with a 5150-designated patient until the patient is stabilized and no longer believed to present a threat to himself or herself or anyone else. Since the premature closure of the Shasta County Mental Psychiatric Facility, without adequate planning, the amount of time a police officer must spend at the hospitals handling 5150-designated patient calls has already increased. Remaining at the hospital to await transfer, as recommended by the Grand Jury, would further tax APD’s resources, typically doubling the average amount of time spent by the officer with each 5150-designated patient. The Anderson City Council appreciates the opportunity to respond to Grand Jury Recommendation Number 12 and hopes that our response is helpful. Response from the City of Shasta Lake (received July 28, 2005): The City of Shasta Lake agrees with the recommendation. Law enforcement services for the City of Shasta Lake are provided by the Shasta County Sheriff’s Department. The Sheriff has provided these services since the City’s incorporation in 1993. It is currently the policy of the Shasta County Sheriff’s department to provide law enforcement personnel to attend 5150-designated persons while they are treated in, and until they are transferred from local unlocked emergency rooms. GJ Reply to the Responses: The Grand Jury accepts the responses from the representatives of law enforcement in the County. We acknowledge the extra time and cost of attending to 5150-designated patients. We remain concerned that persons, who by definition are a risk to themselves or others, even when stabilized, are left unattended in area emergency rooms. A potential for harm within the hospital setting, or after a 5150 designee decides to leave against medical advice, remains a public safety issue.
R13:
The MHAB needs broader community representation. Private physician, local hospital and clinic, and law enforcement inclusion would strengthen the MHAB role as the community advocate for mental health issues. The Grand Jury encourages the BOS to improve the MHAB composition and strongly urges the MHAB to carefully review all major contracts entered into by SCMH. Response from the BOS: the BOS concurs with the Grand Jury’s recommendation regarding the expansion of community representation on the Mental Health Board. The Chairperson will work with the Mental Health Board Membership Committee to recruit a broader cross-section of community members. The MHAB will continue to review the State Department of Mental Health Performance Contract, which governs aspects of the operations of the SCMH Department before it is submitted to the BOS for approval. GJ Reply to the Response: The Grand Jury is satisfied with the response and again encourages MHAB input on all major contracts entered into by SCMH.
R14:
Citizens of Shasta County can take advantage of a new source of state funding for expanded mental health services through the Mental Health Services Act. Similar to new library construction funding a few years ago, this Act awards state tax revenues to individual or joint county proposals for services based on the merits of the plans submitted. Shasta County citizens rallied impressively to support the library and the Grand Jury strongly recommends the BOS encourage a similar community effort. This is an excellent opportunity for increasing access to local services that are both desperately needed and chronically under funded. Mental health services should be prioritized through the public input sessions sponsored by SCMH. The BOS and MHAB should incorporate this community input into any proposal being submitted. Response from the BOS: The BOS concurs with the Grand Jury recommendations regarding the Mental Health Services Act. GJ Reply to the Response: The Grand Jury appreciates the response. The Grand Jury is concerned that a broad community effort to mobilize for real change in local mental health service delivery is not a priority. The BOS consistently ignores community needs for access to local inpatient care by allowing SCMH to export inpatients to out-of-county facilities. While purporting to support the active integration of mental illness into mainstream medicine, BOS policies and SCMH decisions continue to impede this integration. If the BOS, SCMH and area providers cannot unite to address this problem, it is unlikely that cohesive community support will follow.
R15:
The BOS should not rely entirely on staff recommendations when considering future funding and direction of mental health policy in Shasta County. Assigning large, long-term, mo-bid contracts for untried services (Elpida) and closing the super PHF against the recommendations of the MHAB and a citizen’s Community Committee do not represent the best interests of County residents. Since the prior BOS (with the exception of one member) felt economic considerations superceded community recommendations to maintain an inpatient facility, the Grand jury encourages the current BOS (with two new members) to reexamine the issue. From the data presented in this 14 report, the Grand Jury recommends the BOS reconsider the economic factors that led to the decision to close the PHF. We fully appreciate the patient safety issues of the inpatient facility as it was configured prior to its closure. However, our investigation indicates that reopening a basic PHF (non-Medicare) with strict admission criteria is an economically viable and safe alternative to having no local locked inpatient facility at all. Establishing appropriate and affordable local inpatient hospital services would improve patient access ands care and alleviate the problems generated by the closure of the PHF. In conclusion, the Shasta county Grand jury asks the BOS to examine all the facts and govern for its constituents, and not for what benefits SCMH. Response from the BOS: The BOS does not rely solely on the recommendations of staff when considering funding or policy changes. The Board follows an extensive process of review to include a departmental staff report, County Administrative Office review and concurrence, County Counsel review, and Risk Management review. In addition, the Board receives and considers constituent feedback, including Advisory Board input, and public input regarding all Shasta County issues. The BOS voted 4-1 to close the PHF after considering all of the information and several factors including patient safety due to the lack of emergency medical care and the subsequent exposure to litigation. Continued operation of the PHF would require significant funding reductions in other areas of the Mental Health Department. Mental Health Outpatient services would have to be eliminated to ensure the ongoing financial viability of the inpatient unit. Discontinuing outpatient treatment programs would impact a larger population than the closure of the PHF. The loss of outpatient treatment services would impact approximately 87 percent of the total SCMH patient population receiving preventative services, case management, therapy, life management skills, medical management skills, counseling, and other specialty services that minimize or eliminate the need for emergency mental health treatment. Without outpatient treatment the need for emergency mental health treatment services would increase exponentially and exceed the capacity of the PHF. The legal, social, and fiscal impact on law enforcement, social support agencies, and the community in general would be significant. The Grand jury recommendation states that the Elpida contract was a large, long-term, no-bid contract for untried services. The initial term for the Elpida Crisis Residential contract commenced July 1, 2004, and ended on June 30, 2005. The contract was renewed for the same term length for fiscal year 2005-2006 on July 1, 2005. The Elpida Crisis Recovery Center is a subsidiary organization of Crestwood behavioral Health, Inc. Shasta County has had many contractual agreements with Crestwood for similar residential psychiatric services. The Elpida contract was approved by the Board in an amount not to exceed $1,124,200. This amount represents a cost savings for inpatient services that were provided at the PHF. GJ Reply to the Response: The Grand Jury disagrees with the response. With the exception of this final recommendation, all the responses received from the BOS 15 appear to have been provided solely by SCMH; they are taken almost verbatim from a set of responses received earlier from the SCMH Director. This is an indication of a continued over-reliance on staff recommendations. We feel compelled to point out that the Elpida Center is not licensed as a locked inpatient acute care facility (i.e., a PHF) and is not similar to other Shasta County- Crestwood psychiatric ventures. And although some patients are transferred from local emergency rooms directly to Elpida, it remains our contention that expenditures for this facility do little to address the need of County residents for acute inpatient treatment. The Grand Jury remains convinced that developing our own inpatient services is preferable to renting them. We contend that reopening a basic PHF is economically viable, as the yearly cost for a similar facility in Butte County is around $2 million. This represents less than 10 percent of the total SCMH budget, and less than the County is now spending for Elpida and out-of-county inpatient facilities. It is our belief that this will not impact the delivery of outpatient mental health services as described in the response. Conclusion: Prior to, and since the release of our report, public interest in the delivery of mental health services to County residents continues to make news. In April 2005, the BOS held a workshop on mental health issues and listened to patient and provider complaints. In May, the BOS, in conjunction with local hospitals and the Shasta Community Health Center, agreed to seek funding for an outside consultant to review the operations of SCMH. The Grand Jury commends the review and hopes its findings will lead to an improved delivery of care. In July, SCMH psychiatrists finally applied for privileges at one local hospital, but not at the other. A claimed “lack of collegiality” at the hospitals was offered as the reason SCMH physicians had not previously applied for privileges. An unfriendly response is not a reason to seek or deny privileges, nor has it prevented other specialists from attempting to do so. This slow pace of psychiatrist integration into general medicine, and a similar disinterest of the medical community to “buy-in” to the public delivery of mental health care provided by SCMH, remains a significant obstacle to further progress. For example, the declining interest in establishing a joint-partnership, community- sponsored, detoxification center underscores the level of mistrust between providers, SCMH and local government. The integration of mental illness into mainstream medicine cannot occur without willing and effective leadership from all sides. Over the summer months, anecdotal stories from citizens about their inability to access care at SCMH continued to be heard by the BOS. Claims by SCMH administrators that “payer source” is not a factor in the decision to treat patients have been contradicted by both community physicians and families. The Grand 16 Jury remains concerned that there will be no resolution of SCMH bureaucracy and, therefore, gaps in coverage will continue. On a positive note, SCMH will hold a Mental Health Services Act (Proposition 63) public hearing and release its community action plan for funding in October. The Grand Jury applauds the effort by SCMH in soliciting broad community involvement over the past year and looks forward to the presentation of the plan. A major goal of our report was to expand the community discussion about mental health. We believe this has been accomplished. However, discussion is only the first step. Productive action by local government is still lacking. Even with re-opening an inpatient facility, the poor communication between SCMH and the medical community, the ongoing problems with patient access, and an overly bureaucratic mental health department, continue to stymie progress. Report No. 3: Redding Land Purchases The Grand Jury reported on the increasing number of land purchases by the City of Redding, specifically the purchase of an 82-acre vacant parcel along Interstate 5. The parcel, ostensibly purchased as a buffer zone to the City’s southern boundary, is situated mostly in a flood plain and lies outside the city limits. The $1.5 million purchase was funded by a loan to the City’s general fund from the Redding Electric Utility (REU) reserve fund. The report also focused on the use of Redevelopment funding for the purchase of two other properties. The City of Redding responded to four recommendations by letter submitted to the presiding judge of the Superior Court by the Mayor of Redding on July 20, 2005.
Findings & Recommendations
15 findings
F1:
During the Grand Jury investigation the District Manager submitted his verbal resignation to the Board of Directors, and left his position on March 22, 2004. The Board of Directors has employed a new District Manager.
F2:
During the Grand Jury investigation it was reported that several board meetings were cancelled due to a lack of a quorum. The Grand Jury reviewed the minutes for January through December 2003 and determined that three meetings out of twelve were cancelled due to lack of a quorum. To encourage attendance the board changed its monthly meeting time and day to accommodate one of its members.
F3:
The District does not have a Policy and Procedures Manual. At the time of the investigation, the District staff were reviewing a Policy and Procedures Manual from another water district. After personalizing the manual to the District, it will be presented to the board for adoption.
F4:
The former District Manager had never received a performance appraisal during his 25 years of employment with the District.
F5:
The former District Manager reported he used his personal vehicle to conduct District business for approximately one year, due to a lack of funding for District vehicle repairs. During this time, the former District Manager used the District’s gas card to fuel his vehicle in lieu of claiming reimbursement for mileage. The former District Manager used the District vehicle for the remainder of his employment.
F6:
The District continues to maintain accounts that are significantly past due. In the fiscal year 2001/2002 annual audit of the District, it was recommended that old accounts be aggressively collected or “written off” as bad debt. The District has not implemented this recommendation.
F7:
In the 2000/2001, 2001/2002 and 2002/2003 annual audits, the auditing firm noted that the District’s bond agreements require that certain amounts be maintained by the District as reserve or restricted cash to meet current interest and principal requirements. The audit report reviewed by the Grand Jury recommended accounts for note funds, reserve funds, operation and maintenance funds, and a surplus fund. The District has not implemented this
F8:
During the interviews, employees and board members told the Grand Jury that payroll advances were seldom used. However, the auditing firm provided a ledger prepared by the District showing 39 payroll advances during fiscal year 2002/2003. In all of the annual audits reviewed by the Grand Jury, the auditing firm recommended discontinuing the practice of payroll advances. The District has not implemented this recommendation.
F9:
The District has no formal policy for purchasing those items needed for the District’s use. The District maintains several open charge accounts at various local businesses.
F10:
The District uses two cellular phones for general communication. The Grand Jury reviewed three months of cellular phone bills and found that they were in excess of $300 per month.
F11:
The District has no long-term Master Water Plan. A Master Water Plan is an engineering study of the water system that includes preliminary plans with scheduling and cost estimates for future system maintenance, repairs, equipment replacements, and major capital improvements. A plan helps ensure that the community’s present and future water quality and supply needs are met in an efficient and economical matter. This practice allows the District to properly prepare and budget for its future needs.
F12:
The District does not maintain an accurate subsidiary ledger of customer deposits. This list shows customer deposits since the 1970’s. All annual audits reviewed by the Grand Jury recommended that the District update the customer deposit ledger. The District has not implemented this recommendation.
F13:
The District does not maintain an accurate subsidiary ledger of inventory and does not have a process in place for an annual inventory. The fiscal year 2002/2003 audit recommended the District keep a year-end fiscal inventory and maintains an inventory subsidiary ledger. The District has not implemented this
F14:
The District has had to sell off a portion of its investments each year to service the District’s operating expenses. This is depleting the cash balance of the District. The District does not generate sufficient revenue to cover debt service on the 1973 and 1979 bonds and the 1973 Drought Relief loan. The debt service for fiscal year 2003/2004 is $42,782.00. Annual audits reviewed by the Grand Jury recommended that the District take the steps necessary to generate sufficient revenue to cover debt service and operating expenses without depleting cash reserves. The District increased water and sewer rates by 15% in August 2001 and by 20% in November 2003. The former District Manager and the Auditors stated that the rate increases would be insufficient to cover the District’s expenses.
F15:
For the fiscal years ended June 30, 2001, 2002 and 2003, the District had an excess of expenses over revenue of $84,912, $70,034 and $82,041 respectively.