Gran Jurado del Condado de Yuba
2015-2016
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Hallazgos & Recomendaciones
5 hallazgos
F1:
The 2015-2016 Grand Jury finds that MJUSD failed to properly maintain the HVAC system at Lindhurst High School. Specifically, the Grand Jury found no evidence that the water was being treated per documented specifications as found in a number of magazines and periodicals related to building maintenance: Contracting Business, ACHR News, and Facility Management. This failure may have potentially exposed the students, staff and public to Legionnaires’ disease or Pontiac Fever (CDC). In addition, the lack of water treatment and maintenance has led to the water lines becoming corroded and blocked, reducing the efficiency of the system (Contracting, 2010) and putting pressure on the Central Plant, “resulting in an increased load and ware on the machinery” (MJUSD, Aug 14, 2016). In a public letter, the MJUSD Superintendent indicates knowledge of the hard water in this area (MJUSD, Aug. 25, 2015). In light of this lack of maintenance on the system, the chillers failed prematurely. The chillers had only eight years of actual wear and the Grand Jury’s research showed that, with proper maintenance, they have a life expectancy of around 20 to 30 years (Grassi, 2013).
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R1:
The 2015-2016 Grand Jury recommends that MJUSD set up a maintenance schedule per the manufacturer’s specifications of the new independent HVAC systems. The 2015- 2016 Grand Jury recommends that MJUSD set up a maintenance schedule for all HVAC support equipment including the chillers and controls. This is to be implemented upon the installation of the new systems. (F1) The 2015-2016 Grand Jury recommends that MJUSD clean or replace the underground water lines that have become corroded and blocked (MJUSD, 2015). The 2015-2016 Grand Jury recommends that MJUSD maintain proper water treatment for all of the HVAC systems at Lindhurst High School. This is to be done upon the installation of the new systems. (F1)
F2:
The 2015-2016 Grand Jury finds that MJUSD failed to maintain a log detailing work done on the HVAC system as well as any noted irregularities of the HVAC system at Lindhurst High School. The Grand Jury had requested to see the maintenance log but was advised by MJUSD that they were unable to locate or did not have the log. In addition, the Grand Jury finds that MJUSD has very little documentation on work done through outside contractors.
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R2:
The 2015-2016 Grand Jury recommends that MJUSD set up a maintenance log for each HVAC system; documenting the date, a brief summary of the issue, and what was done. In addition, the Grand Jury recommends that MJUSD set up a filing system and maintain all work orders, purchase orders, contracts and any other paperwork documenting outside contracting work done on the HVAC system. (F2)
F3:
The 2015-2016 Grand Jury finds that MJUSD failed to act on a work order indicating a problem with the HVAC system at Lindhurst High School. Per Grand Jury interviews, this failure to act significantly contributed to the compressor being destroyed by a loose screw. This left the students at Lindhurst High School without air conditioning in triple-digit heat causing at least two walk-outs (Luery, 2015 and Barron, 2016).
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R3:
The 2015-2016 Grand Jury recommends that MJUSD address work orders immediately, document what actions were taken and maintain all documentation regarding work orders. This is to be implemented immediately. (F3)
F4:
The 2015-2016 Grand Jury finds that the personnel in MJUSD Facilities and Energy Management Department do not have enough knowledge and experience in handing the HVAC systems. The Grand Jury was advised, during interviews, that the technician currently assigned to maintain the HVAC system is unfamiliar with the system. Page | 44
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R4:
The 2015-2016 Grand Jury recommends that MJUSD ensure proper training is provided for the technicians responsible for the HVAC system. This is to be implemented immediately. (F4)
F5:
The 2015-2016 Grand Jury finds that MJUSD is currently addressing the HVAC problem with an emergency HVAC replacement project (Barron, 2016). Per K. Barron and a 2015 newsletter from MJUSD (2016); this is a multi-stage project with the first stage addressing Lindhurst High School’s C and F buildings. Building C should have a new system in late March to early April 2016, Building F in late April 2016. Work on a new HVAC system for the gym, locker room and classrooms in Building E is expected to start by early fall of 2016. Research documentation shows that proper maintenance will reduce energy costs (ACHR, 2005) as well as reduce the potential risk of exposure to Legionella bacteria which is associated with Legionnaires Disease and Potomac Fever (CDC).
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R5:
The 2015-2016 Grand Jury recommends that MJUSD ensures that the projects of replacing the HVAC system for Lindhurst High School is completed. The gym, locker room and classrooms in Building E to be started by September 1, 2016 and completed by March, 2017. (F5)
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R60-80:
patients are seen by the doctor or FNP per week. The doctor advised that he tries to see patients within 24 hours of a submitted medical request slip, but generally it is 48 hours. During interviews, the Grand Jury was advised that a patient with chronic non-emergency complaints may be dropped lower on the list. The Grand Jury interviewed an ex-inmate that had been incarcerated in Yuba County Jail for four months in 2015. This inmate advised they had fallen while working in a Sheriff’s Work Alternative Program (SWAP). The inmate filled out a medical slip to see the doctor. The inmate had filled out four medical slips prior to seeing one of the nurses; not the FNP or the Doctor. The inmate was told that they had soft tissue damage and was given “Aleve” for the pain. They continued to request to see the Doctor or the FNP, and had filled out four more slips and saw two more nurses before finally seeing the FNP. The inmate was told that the Doctor was on vacation and out of the country. The inmate saw the FNP two weeks after the initial injury and was again diagnosed by the FNP with soft tissue damage. They continued to submit medical slips and stated that they had submitted 18 slips in a 28 day period. Copies of the medical slips were provided to the Grand Jury. When the inmate did see the Doctor, it was for another medical issue. He saw the inmates arm and stated it was broken. A portable X-ray machine was brought in and it was determined that there was a radial head fracture. The inmate was then taken to a doctor outside the facility where the arm was set and cast. In addition to the delay in treatment of the arm, the witness stated that they had to argue to obtain the migraine prescription in possession when booked. The Yuba County Jail Manual (1999) states: “No arrestee who is determined to be intoxicated or under the influence of drugs shall be given any medication. If the Booking Officer believes it is necessary for the arrestee to be given the medication, the officer shall refer the person to the nurse or in her absence, transport the person to the hospital or clinic to be seen by a physician.” Page | 27
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F8:
The medical unit is housed in cramped quarters below street level as observed during the Grand Jury YCJ tour. Until the upstairs administrative staff is moved to a remodeled facility expansion plans for the medical unit are on hold. 2014-2015
F9:
As determined during the Grand Jury’s tours of the jail, the physical layout of the jail raises safety issues for the staff and the inmates, most notably the section built in 1962 known by staff and inmates as the “dungeon”. 2014-2015
F10:
A copy of a summary of the Consent Decree is provided to the inmates upon booking; however, it is not identified as a “Consent Decree”, as a mandate for the jail to follow, nor does it explain that a full copy can be obtained in writing (Yuba County Inmate Handbook). The Consent Decree (1978) states it is to be posted in the ‘Libraries and the Women’s Tank’. The Undersheriff advised that the Consent Decree is posted in the ‘Law Library’ and that the information is available in the Inmate Handbook. 2014-2015
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R8:
Because the expansion of the medical unit quarters does not involve making use of any of the upstairs administrative space to be vacated, remodeling of the nearby storage area should be planned and completed by June 30, 2016.” Through interviews, the 2015-2016 Grand Jury learned that the 2014-2015 Grand Jury Report was used to justify Yuba County’s request for a $20 million improvement grant through SB 863. The Board of State and Community Corrections Executive Steering Committee recommended that Yuba County receive this funding. The 2015-2016 Grand Jury was also informed that the 2014-2015 Grand Jury Report was, in part, the reason that Yuba County was awarded the Grant. This Grant will allow the Sheriff to construct a new building that will house a new, larger, medical unit. This will alleviate the current cramped conditions. “2014-2015
R9:
It is recommended that the Sheriff and the Board of Supervisors explore all available federal, state, county, and grant funding sources to build a new facility or upgrade the 1962 portion of the facility utilizing optimum architectural design for the health and well-being of staff and inmates. This will assist the Correctional Officers in managing inmates and to meet the needs of the growing inmate population.” In the Sheriff’s Response and during interviews, the 2015-2016 Grand Jury was advised that the Sheriff’s Office receives and researches lists of available grants. The Sheriff’s Office does apply for grants that are applicable to their needs, and, in fact, has obtained a large grant to update the medical facility. “2014-2015
R10:
The Yuba County Inmate Handbook is to be corrected to identify the Consent Decree as a legally enforceable Judgement, and Page | 22 that a copy of which can be obtained upon request. The Consent Decree is to be posted in the ‘Libraries and the Women’s Tank’.” At the time of booking, each inmate is provided an Inmate Handbook in either English or Spanish. The Handbook is not the Consent Decree, however all of the applicable requirements listed in the Consent Decree are addressed in the inmate Handbook along with other information. The Consent Decree does not specify that the inmate Handbook or summary must refer to the Consent Decree by name as the reference for this information, therefore the inmate Handbook was not changed. A full copy of the Consent Decree was located in both the Law Library and in the Female Program Room. This completes the continuity part of this report. The second part of this report covers the current conditions in the jail as determined through observation, interviews and the review of documents. 2015-2016 Grand Jury Report The Yuba County Jail Administration and Staff are responsible for approximately 400 inmates with the number fluctuating due to people coming in and being released. A brief review of the laws and manuals governing the correctional system as well as the jail logs shows this responsibility is complex. The Yuba County Grand Jury investigated the Mental Health and Medical facilities, the Safety of the inmates and staff, the Kitchen and Meal preparation, the Exercise yards and equipment, the Libraries, and the Vocational/Education opportunities. Mental Health Services Sutter-Yuba Mental Health (SYMH) verified that the full-time Crisis Counselor has the required education necessary for the position. This counselor was hired through a Community Services grant and works a 40 hour week, generally in the late afternoon and evenings. A second, part time, Crisis Counselor has been hired and comes in one day a week to help with inmate mental health requests. In addition to the two Crisis Counselors, the Sheriff advised that SYMH hires and provides the psychiatrist and a Tele-psych (internet) psychiatrist. The Under-sheriff advised that the in-house psychiatrist comes in on Sundays. The psychiatrist is scheduled to work four hours but will stay up to eight hours when needed. This psychiatrist primarily works with inmates being screened for their competency to stand trial. The Tele-psych is scheduled for eight hours on Wednesday and is available, via telephone, during the week. The inmates have 24 hour access for emergency psychiatric care and around 100 hours a week of non-emergency mental health treatment/counseling. A Bureau of Justice 2006 report states that 64% of jail inmates throughout the nation have mental health problems. Assuming that this same statistical information applies to the Yuba County Jail; that would be an excess of 200 inmates. With 100 treatment hours available this allows for less than 30 minutes of non-emergency one-on-one mental health counselling/treatment per inmate per week. The Under-sheriff advised the Grand Jury that they have resumed group counselling which will allow more individuals access to a form of treatment. In November, 2015, Yuba County was awarded a $20 million grant through SB 863. Page | 23 This grant shall be used to build a new annex next to the existing building which will include additional rooms for counselling and classroom instruction. During an interview with medical staff, the Grand Jury was told that due to the increased use and potency there has been a marked increase in mental health problems. The National Institute on Drug Abuse (2015) confirms that there has been a rise in the use of marijuana since 2007. SYMH also advised they have hired a Forensic Therapist. The Forensic Therapist specializes in mental health and criminal justice. The Forensic Therapist will oversee the mental health personnel working with law enforcement in both Sutter and Yuba Counties; the Sheriff’s Offices, Probation and Juvenile Hall. The Grand Jury was informed that this position is funded through the Community Correctional Partnership. During the investigation, the Grand Jury was informed that SYMH presented a Mental Health First Aid course to the jail staff in December, 2015. All Correctional Sergeants have been certified to instruct other courses: Intake Medical Screening, Mental Health Issues in Jail, Attempted Suicide, and Suicides and Death. Each course is presented at least once a year. One Sergeant is also certified to instruct Suicide Prevention in the Correctional Facility and presents this instruction annually to all custody and medical staff. During tours and interviews, the Grand Jury was informed that inmates displaying suicidal tendencies or threatening suicide are placed in a Safety Cell. This is a small cell, approximately 7’x7’, with firm padding on the walls, no furnishings, a single light, a window, and a drain hole in the floor. If necessary, clothing is removed and inmates are given specialized clothing that will tear easily and cannot be used for suicide. An inmate is only placed in a Safety Cell with the approval of the facility administrator, the watch commander or the physician. These inmates are checked every 15 minutes and a medical assessment is completed within 12 hours of placement. A mental health opinion is secured within 24 hours. If the inmate remains in the cell after the first medical assessment, he/she is medically checked every 24 hours at a minimum. Jail Administration advised the Grand Jury that arrestees are regularly taken to SYMH prior to booking for evaluation to ensure they are fit for incarceration. If an arrestee is deemed unfit, a mental health hold is placed and he/she may be taken to Rideout Memorial Hospital or held at SYMH. Inmates may be taken to SYMH for treatment if necessary. When asked if any inmate has been taken to SYMH for treatment in the past year, Jail Administration cited one incident that involved an inmate refusing to take prescribed medication and it was determined that, for safety reasons, SYMH personnel would administer the medication. Jail Administration told the Grand Jury that a deputy may have to stand by with the arrestee or inmate depending on the severity of the charge and circumstances surrounding the person’s arrest. UC Davis School of Law (UCD) has been assigned by the Eastern District Federal Court to monitor the Yuba County Jail’s compliance with the Consent Decree. During their presentation to the 2015-2016 Grand Jury, the UCD students expressed concern over the medical and mental health conditions in the jail. They advised that the jail psychiatrist has a blanket policy of Page |
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Hallazgos & Recomendaciones
3 hallazgos
F1:
The 2015-2016 Yuba County Grand Jury finds that the Yuba County Jail has shown considerable improvement in the mental health care being provided to the inmates. They now have two crisis counselors, one part-time and one full-time; two part-time psychiatrists (one available through Tele-psych); and a full-time forensic mental health therapist. The inmates have approximately 100 hours of non-emergency mental health care available to them per week. A Bureau of Justice 2006 report states that 64% of jail inmates throughout the nation have mental health problems. Assuming that this same statistical information applies to the Yuba County Jail; that would be an excess of 200 inmates. With 100 treatment hours available this allows for less than 30 minutes of non- emergency one-on-one mental health counselling/treatment per inmate per week. The Jail has reinstated group counsel sessions which allows more inmates an opportunity for treatment during the week. In November, 2015, Yuba County was awarded a $20 million grant through SB 863. This grant shall be used to build a new annex next to the existing building which will include additional rooms for counselling and classroom instruction. Correctional Officers receive annual training in suicide and suicide prevention, and mental health issues in a jail facility. The Officers also received “Mental Health First Aid” which is an 8 hour training course. During the UC Davis (UCD) presentation to the Grand Jury, UCD advised of two suicide-by-hanging attempts, both suicide attempts were interrupted by other inmates. Prior to each situation each inmate had told UCD that they had asked for mental therapy; they wanted to see a psychiatrist, yet no treatment was offered. With the Realignment Act, some inmates are now being housed for longer periods of time, up to five years. Inmates with mental health issues could benefit from a complete evaluation and a recovery oriented treatment plan (Interpretive Guidelines). In 2015, the Zur Institute wrote that there is no textbook definition of the standard of care in the mental health field. Based on the statistics cited, the 100 hours per week allotted to treatment of mental health issues appears to be inadequate for the number of inmates potentially requiring care. Page | 31
Recomendaciones relacionadas (2)
R1:
The 2015-2016 Yuba County Grand Jury recommends that the Sheriff apply to the Board of Supervisors to provide funding and hiring of a full-time psychiatrist that could allow the Jail to work on a mental health treatment and care plan with a focus on work and/or education. The 2015-2016 Yuba County Grand Jury further recommends that the Board of Supervisors approve funding for a full-time psychiatrist. This should be accomplished by the end of the 2016-2017fiscal year. (F1)
R2:
The 2015-2016 Yuba County Grand Jury recommends that the Sheriff apply to the Board of Supervisors to provide funding and hiring of a full-time medical doctor that could reduce the pressure on the medical staff and decrease the time it takes to see a doctor or the Family Nurse Practitioner. The 2015-2016 Yuba County Grand Jury further recommends that the Board of Supervisors approve funding for a full-time medical doctor. This should be accomplished by the end of the 2016-2017fiscal year. (F1)
F2:
The 2015-2016 Yuba County Grand Jury finds that the Yuba County Jail has increased the number and quality of its medical personnel by hiring a full-time Family Nurse Practitioner (FNP) who will assist the doctor in the care and treatment of inmates. One of the current LVN’s has passed the RN course, has applied for an interim permit and is expected to receive the permit prior to the release of this Grand Jury Report. This interim RN may receive permanent RN status within a few months. The Sheriff has approached the Board of Supervisors and received funding for the Correctional Facility RN pay with the goal of maintaining a valuable employee while increasing the skill, education and experience in the Medical Unit. The doctor stated that he tries to see an inmate within 48 hours of the inmates’ request. The doctor and nurse combined see 60-80 patients a week and it can become difficult for an inmate to get an appointment with the doctor which could cause a delay in treatment. The Grand Jury also interviewed an ex-inmate who states the inmate was miss-diagnosed by several Licensed Vocational Nurses (LVN) and the FNP as having soft tissue damage. It wasn’t until they saw the doctor, 28 days after the initial injury, that the inmate was diagnosed with a radial head fracture. However, in further researching the medical
F3:
The 2015-2016 Yuba County Grand Jury finds a number of studies have shown the benefit of providing inmates with an opportunity to earn their GED diploma, which makes this a vital issue to be considered by local, state and national legislators. An article by Matthew Clark in 2014 stated that a 2013 RAND report integrated more than 30 years of previous research on education and recidivism rates. The report states that “inmates who participated in correctional education programs had 43% lower odds of returning to prison than inmates who did not.” (Clark, 2014). It goes on to state that “the odds of an offender finding employment after release from prison was 13% higher for those who participated in academic or vocational programs compared to those who did not.” (Clark, 2014). Another study by John Nuttall (2003) broke down two groups, offenders under the age of 21 and over 21. “Offenders under the age of 21 who earned their GED diploma were 14% less likely to return to prison within three years, while prisoners over 21 were 5% less likely to return to prison after earning a GED diploma. Education in prison systems is an effective way to lower recidivism.” (Nuttal, 2003). Yuba County Jail does offer GED courses that cover the five Core Requirements as well as grammar and spelling. They work with inmates to give them an opportunity to obtain their GED certification, however they are unable to provide the GED certification test in- house and it is not always practical to transport an inmate outside the jail and watch over him/her for six hours. The Jail Administration advised the Grand Jury that they are hoping to provide the GED certification exam in-house in the future. Page | 32
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R3:
The 2015-2016 Yuba County Grand Jury recommends that the Sheriff continue to focus on setting up an in-house GED testing program with the goal of implementing such a program within the 2017-2018 fiscal year. (F3)