EXHIBIT B

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ReviewofSantaBarbaraCountyJailMedicalServicesExecutiveSummary

ScottA.Allen,MDIntroductionIhavebeenaskedjointlybycounselrepresentingtheCountyofSantaBarbaraandcounselrepresentinginmatestoprovideanindependentassessmentofthemedicalcareprovidedbytheCountyinitsjailsystemandtomakerecommendationsasindicatedaspartofanalternativeresolutionprocess.StandardsWhileitisunderstoodthattheSantaBarbaraCountyJailisnotcurrentlyaccreditedbytheNationalCommissiononCorrectionalHealthCare(NCCHC),theStandardsforServicesinJails(2014Ed.)providesausefulbenchmarkforminimumstandardsforjailhealthservicesintheUnitesStates,andIwillrefertothosestandardsinthisreport.1InadditiontotheNCCHCstandards,Iwillmakereferenceinthisreporttocommunitymedicalstandards.Whiletheacceptableclinicalpracticeofmedicineallowsforawidevarietyofapproachestopractice,communitymedicalstandardsarethepointinwhichthegreaterbodyofexpertsandpractitionersinthefieldhavefoundagreementandareestablishedbythestandardofcareacceptedbythecommunityatlarge.Thereisnoseparateorunequalstandardofcareforinmatesofcorrectionalinstitutions;therearemerelylogisticalchallengesandreasonableaccommodationsandmodificationsofstandardmedicalapproachesthatareadirectresultoftheconstraintsofconfinementsettings.Thoseexceptionsandaccommodationstosecurityneedsshouldbeminimalandrarelyinterruptandneverpreventessentialhealthcaredelivery.Totheextentthatprovidingmedicalcareinacorrectionalsettingraisessomeuniquechallenges,Idrawonmyknowledgeofstandardsandpracticesasaphysicianexperiencedincorrectionalhealthcareandfamiliarwithstandardsofthefield.Ingeneral,whenIrefertominimalcommunitystandards,IrefertoservicesapatientwithMedicaidorMedi-Calcoveragewouldlikelybeeligibletoreceiveinacommunityhealthcenterornon-correctionalcountyfacilityorsimilarsetting,1WhenIcitethe2014NCCHCStandardsforHealthServicesinJails,thestandardisinthefollowingformat:theletter“J”followedbyletter“A”through“I”andanumber.Forexample,thestandardforReceivingScreeningisJ-E-02.

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recognizingthatinmatesarenotconstitutionallyentitledtothemostsophisticatedcaremoneycanbuy,buttoadequatemedicalcare.Finally,whenIdomakereferencetoconstitutionalstandardstohealthcare(basedontheEighthAmendmentprohibitiononcruelandunusualpunishment)Idosonotasalawyer(whichIclearlyamnot)butasaphysicianwithextensiveexperienceinactuallyprovidingthatlevelofcareinjailsandprisonsandinhelpingthecourtstodefinethatstandardinpracticalterms.SpecificFindingsandRecommendationsThesectionthatfollowsoutlinesspecificdeficienciesnotedinmyreview.IfthereisarelevantNCCHCstandard,Inoteit.2Noadversefindingisbasedsolelyonaninmateclaimmadeduringaninterviewalthoughsomewereidentifiedfirstbyaninterview;allproblemsdescribedwereverifiedeitherbythemedicalrecordorbystafforinsomecases,byboth.

1. AccreditationstatusFinding:

•Currently,theSantaBarbaraCountyJailHealthServicesarenotaccreditedwiththeNationalCommissiononCorrectionalHealthCare(NCCHC)ortheAmericanCorrectionalAssociation(ACA).

Recommendation:•Thedepartmentshouldmoveforwardwiththeprocessofpreparingfor,applyingforandsecuringaccreditationwiththeNationalCommissiononCorrectionalCare.

2. PoliciesandProcedures:

Findings:•Inthecourseofthisinvestigation,Ihadsomedifficultyinobtainingacopyofthepoliciesandproceduresastheywerefelttobeproprietarybythemedicalcontractor.

2MyinclusionofthestandardsismerelyforreferenceandalthoughIdodescribedeficiencies,inclusionofthestandardinthissectiondoesnotmeanIhavenecessarilyconcludedthatthestandardisnotbeingmet.IdosummarizestandardsthatIfeelarenotbeingmetlaterinthisdocument.

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•ThepolicieswereeventuallyprovidedtomeandIfoundnomajorinconsistencieswithNCCHCminimumstandards.(J-A-05)

•ThepoliciesprovidedwereCFMGpolicies,andwerenotsitespecifictoSantaBarbara.

•Therewasnopolicyfordealingwithtransgenderpatients.•Thepolicyondrug/alcoholwithdrawaldidnotincludedetailedguidelinesandflowsheetsfornursestomakeclearthefrequencyofassessmentandspecificfindingstobenotedandrecordedduringthemonitoringperiod.

Recommendations:•ThepoliciesandproceduresgoverningthedeliveryofmedicalcareoftheSantaBarbaraCountyJailshouldbepromulgatedbytheCountyitself,andtheCountyshouldexerciseownershipandcontroloverthosepolicies.

•TheCountyshouldhaveapolicyfordealingwiththemedicalcareoftransgenderpatients.

•Thedrug/alcoholwithdrawalpolicyshouldbesupplementedbyclearclinicalguidelinesandflowsheetstoenhancecompliancewithstandardclinicalprotocolsreferencedbythepolicy(CIWAandCOWS).

3. Staffing:

Findings: •Currentlynursingstaffingremainsshortofthedepartment’sownstatedplanandisnotsufficienttodeliverappropriatemedicalcare.Areasonablestaffingrecruitmentplanisinplace(withonenotableexceptioninintakedescribedbelow),andeffortstorecruitnewphysiciansandnursesisunderway,butfouryearsafterthedepartmentwasmadeawarebyconsultantsofstaffingdeficiencies,thestaffinglevelsproposedbythedepartmenthavenotyetbeenmet.

•Theoneshortcomingofthecurrentstaffingplanistheabsenceofanursingpostforintake.Theintakenursingresponsibilityishandledbynursesbeingpulledfromotherposts.Whenthathappens,otherfunctionsshutdown.Intakeisacriticalpostinajailfacility,andassuch,itshouldhaveitsowndedicatednurse.

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•Thefacilityisunderstaffedformedicalprovidersandthescheduleisinadequatetocovertheneedsofa24/7facility.Jailsarehighturnoverinstitutionswithmanyadmissionsandreleases,andaninmatepopulationofteninpoorhealth.AccordingtotheSheriff’s2013-2015TriennialReport,themedicalprogramhandledover13,000sickcallsperyear,orroughly35sick-callsaday.

•Thecurrentphysiciancoverageforthejailisonlya0.4FTEposition,withphysicianpresenton-siteforonlythreedaysaweek,andthosedaysaregroupedtogethermid-week.Asaresult,thereisnophysicianpresentforfourcontinuousdayseveryweek.Thisistotallyinappropriateandcreatesunjustifiablerisksandliabilities.

•Currentphysiciansalariesmaynotbecompetitivewithothercorrectionalmedicineopportunitiesinthestate.(J-C-07)

Recommendations:•Thedepartmentshouldworkwiththecontractortoestablishappropriatemedicalprofessionalstaffinglevelsandthenworktomaintainthemandadjustthemtoaddresschangingneeds.

•Whentargetstaffinglevelsareachieved,ongoingreassessmentofchangingneedsandappropriateadjustmentstostaffinglevelsisessential.

•Themostcriticalshortcominginthecurrentnursingstaffingplanistheabsenceofanurseprimarilyassignedtointake.Theroleofintakenurseisacriticalfunctionatajailfacilityandshouldnotbestaffedbynursespulledfromotherposts.

•GiventhevolumeofintakesandreleasesattheSantaBarbara.ThestaffingplanshouldincludeatleastoneboardcertifiedFTEphysician,supplementedbyoneFTEphysicianextendersuchasanursepractitioner.

•Effortshouldbemadetomakesalariescompetitivewithcorrectionalhealthsalariesinthestate.

4. PhysicianQualifications

Findings:•Thereiscurrentlyonlyonephysicianmedicalprovideratthemainjail.

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•Areviewofmedicalrecordsrevealsthatthephysician’smedicaldocumentationofcareispoorandcareofchronicconditionsdoesnotmeetreasonablecommunitystandards.

•Theonlyphysicianisnotboardcertifiedininternalmedicine,familymedicinenoremergencymedicine(thethreeappropriatespecialtiesforaprimarycareproviderinanadultjail).

Recommendations:•Thedepartmentshouldworkwiththecontractortoestablishappropriatemedicalprofessionalproviderstaffinglevelsandthenworktomaintainthemandadjustthemtoaddresschangingneeds.

•Thephysician(s)providingoversiteandcareattheSantaBarbarajailsshouldbeboardcertifiedininternalmedicine,familymedicineoremergencymedicine.ThephysicianwhowouldalsoserveastheResponsiblePhysicianwithultimateauthorityonallclinicaldecisionsconsistentwithNCCHCpoliciesshouldbeafull-timeposition.

5. OvercrowdingandImpactonHealth

Findings:•Accordingtothe2016-2017SantaBarbaraCountyGrandJuryReport“Since1988,theCountyhasbeenunderacourtordertoreducethedailyjailpopulationtoan819approvedbedcapacity.However,theaveragepopulationfrequentlyexceeds1,100.”•From2017GrandJuryReport“TheMainJail,originallybuiltin1971,hasbeendescribedasold,antiquatedandovercrowded.Itisratedfor659inmates,andtheMediumSecurityFacilityisratedforanadditional160inmates.Theaveragepopulationatthejailtendstobeover1,100.”

•Overcrowdingcanimpactbothmentalhealthandphysicalhealth.Overcrowdingmatthreatenphysicalhealthbybringingpeopleintoclosecontactthatisconducivetothetransmissionofinfectiousdiseases,rangingfromcommonrespiratoryandgastrointestinalviruses,tobacteriaandeventuberculosis.•Whilethecurrentmedicalprogramdidnothavegoodsurveillancedata,Ihappeneduponahighnumberofinmateswhoactivelyhadorhadrecentlysufferedfromaseriousskininfectionduetoadrugresistantformofthebacteriastaphylococcusaureus,knownasMRSA.Althoughwithoutfulldataitisdifficulttomakeafirmconclusion,thisMRSAproblemislikelyareflectionofovercrowdingcombinedwithsanitationissues.

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•Bothovercrowdingandpoorhealthcarehavebeenfoundbythefederalcourts,includingtheU.S.SupremeCourt,aspotentialevidenceofunconstitutionalcare.Asaconstitutionalissue,theobligationoftheCountytoaddressovercrowdingandhealthcareimpactscannotbeexcusedsimplyduetofinancialpressuresfacingtheCounty.Recommendation:•Astheimpactofovercrowdingimpactsthehealthinthefacilities,theCountymustdevelopatimelyplantoaddressovercrowding.

6. Physicalspaceformedicalcare:Findings:

•Thereisnoadequatecentralizedclinicspaceintheoldjail.Clinicspaceandexamroomsisdispersedthroughoutthefacilityimpactingefficiencyofcareandrequiringthesupportofanadditionalsecurityofficerforeachclinicspaceinoperationatanygiventime.•Intakescreeningroomdoesnothaveadoorandthereforedoesnotprovideauditoryisolationforconfidentialityofsensitivemedicalinformation.Lackofauditoryprivacymightleadtoincompletedisclosureofcriticalhealthinfoandmissedopportunitiesforriskmitigation.Allclinicandscreeningspacesshouldhaveauditoryprivacyforhealthprofessional–patientinteractions.•Adequateclinicalspaceinthemainjail,aswellasdevelopmentofisolationcellsthatarenothiddenorremotelylocated,willrequiresubstantialarchitecturalmodifications.

•Thereisinadequateofficespacetosupportthemedicalworkforce,andinadequatespaceforstorageofsupplies.(J-D-03)

Recommendations:•Thedepartmentshouldexamineandconsideroptionstodevelopnewerandmoresuitableclinicspacetosupporthealthoperation;spaceshouldbelargeenoughtoaccommodateclinicaloperationswhilealsosecuringappropriateprivacyforpatients.Isolationcellsshouldhavedirectlineofsiteandbewithinhearingortwowayintercomorcallbutton.

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•ItwouldbeadvisabletoconsultcloselywithcountycorrectionalhealthstaffontheplansforclinicspacebeforebreakinggroundontheNorthernBranchproject.

7. SanitationandEnvironmentalHealthIssuesFindings:

•Thebuildingisoldandindisrepair.Overcrowdingcreatesadditionalchallengestosanitationandcleanliness.Duringmyvisit,floors,countersandotherserviceswereinpoorconditionandwerenotclean.Rubbishanddebriswerefoundonfloorsandhallways.Boxesandothernon-trashitemswereimproperlystoredinhallwaysandoffices.•Poorconditionofphysicalplantandpoorcleanlinesshavebeennotedinthisfacilityinthepast.•Ifoundissuesofsanitationtobeaproblemthroughoutthefacility,butworstintheoldestareasofthebuilding.(J-B-01)

Recommendation:

•ThecountyshouldformallyconsultanEnvironmentofCareexperttoevaluatethefacilitytomakerecommendationstoaddressissuesofcleanlinessandsanitation.

8. InfirmaryorIntermediateLevelofCare

Findings:

•Acrosstheentiresystem,theSantaBarbaraCountyJailhasnoabilitytoprovideinfirmarylevelorintermediatelevelofcare.Asaresult,inmatepatientsrequiringhigherlevelofmustbetransferredtooutsidefacilitieswiththeattendanthighermedicalandsecuritycosts.•Themainjaildoeshaveaso-called“medicalunit”butthereisnothingabouttheunitthataffordsahigherlevelofmedicalcare.Itissimplyadormitorywhereinmateswithmedicalconditionsarehoused.(J-G-03)Recommendation:•Thedepartmentshouldexploreoptionsfordevelopingatleastonefacilitythatcouldprovideahigherlevelofmedicalcaresuchasinfirmaryorsub-acutelevelsofcare.

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9. ScreeningonIntakeandInitialHealthAssessments:

Findings:•CurrentintakedoesnotmeetNCCHCstandards(J-E-02andJ-E-04)becausenotallincominginmatesarebeingscreened.Inrandommedicalrecordreviews,Iidentifiedrecordsofinmateshousedinthefacilityforovertwoweekswithnomedicalscreeningatall.Recommendations:•Thedepartmentshouldcontinuetoensurethatallnewlyarrivedinmatesarescreenedonarrivalbylicensednursingstaff.•Thestaffingplanshouldincludeanintakenursingpostcommensuratewiththehighvolumeofthefacilityandcriticalnatureofthisfunction.(J-E-04).

10. QualityManagement:

Findings:•QualityManagement(QM)forthemedicalunitdoesnotappeartoexistattheSantaBarbaraJail.•CFMGpolicyrequiresaQMprogramandthereareplanstostandupaQMprogramincomingmonths.(J-A-06)Recommendation:

•ThedepartmentshouldcontinuetodevelopacontinuousQualityManagementprogram.Informationgleanedfromwell-functioningQMprocesseshelpsadministratorsimprovebothqualityofcareaswellasefficiencyofcareandcanhelpidentifyopportunitiesforcostcontainment.

11. UtilizationManagement:

Findings:•Beyonddelegatingauthoritytothevendor(CFMG),thereisnoapparentprocessfortheCountytoreviewandapproveuseofoutsidecareforpatientsrequiringsub-specialtyandhospitalservices.Recommendation:

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•Thedepartmentshoulddevelopautilizationmanagementprocess.Managedcareapproachestoallocatingresourcesforhighcostcarehavebecomeanestablishedmechanismforstandardizingandcontrollingutilizationofhealthresources.•Thedepartmentcouldconsultwithotherdetaininginstitutionsbothinthestateandelsewheretolearnmoreabouttheutilizationmanagementprocessforincarceratedpopulations.Effectiveutilizationmanagement,whileaimingtoachievecostcontainment,mustnotadverselyimpactaccesstocare.

12. MedicalRecords:

Findings:•Medicalrecordsarecurrentlypaper-based.In2017,apaperbasedmedicalrecordsinajailsystemiswoefullyinefficientandinadequate.•Areviewofrecordsrevealsapatternofunsignedtelephoneordersbyphysicians–someasoldasoneweek–andkeylabresultsthathavebeenfiledwithoutnotationoracknowledgmentbyaphysicianornursepractitioner.Documentationofclinicalencountersisoftenbriefandincomplete.•Thereisalmostnodocumentationbyphysiciansofpatienteducationabouttheirillnesses,theirlabortestresultsorthetreatmentplan.•Documentationbythecurrentnursepractitioner,whiletypedandlegible,over-usedshortcutsandgeneral,non-specificwords.•Inothercharts,handwritingisfrequentlypoor,andsomeprovidersdonotuseasignaturestampsoitisuncleartoareviewerwhowrotethenoteandtheirprofessionalcapacity(doctorversusnurseorotherstaff).•Problemlistsareoftenincomplete.Labandradiologyresultsarefrequentlyfiledwithoutprovidersignoffandabnormalresultswereoftenfiledwithoutanydocumentedinterventiontoaddresstheabnormality.(J-H-01andJ-H-03)•ThedepartmenthasplansformovingtoanElectronicHealthRecord(EHR)inthefuture.Atthetimeofthisreport,thisnewsystemisnotyetdeployed.Recommendation:

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•ThedepartmentshouldfollowthroughwithitsplantodeployacorrectionalElectronicHealthRecord(EHR)andprovideongoingITsupporttoboththenetworkinfrastructureandITsupportforendusersofthesoftware

13. ChronicDiseaseManagement

Findings:•Chronicdiseasemanagementisinadequate.(J-G-01)Myreviewfoundmanagementofchronicillnessessuchasasthma,diabetes,HIVandhypertension,amongothers,tobeadhoc,incomplete,inconsistent,andreactiveasopposedtoproactive.Careofchronicdiseasesappearstobedrivenmorebyinmateself-advocacythanbywidelyacceptedclinicalguidelines(includingbutnotlimitedtothosereferencedbytheNCCHCandFederalBureauofPrisons).•Thereisnocomplete,accurateorreliablelistofpatientswithchroniccareconditions.•Therearenoprotocolsthatarefollowedforongoingcareofchronicillness,suchasregularlyscheduledfollowupvisits(thoseappeartobescheduledinconsistently–ifatall–byindividualphysiciansandnurseswithnoclearlydocumentedlogicorclinicalreasoning).•Inanumberofreviewedcases,careofchronicdiseasepatientsappearedtobenegligentandoverallcareofchronicdiseasescouldbecharacterizedasdeliberatelyindifferent.Recommendation:

•TheDepartmentshoulddevelopachronicdiseasemanagementprocessthatreferencesestablishedguidelines(bothcorrectionalandcommunity)forthemanagementofcommonchronicconditionssuchas,butnotlimitedto,diabetesmellitus,asthma,hypertension,HIVandhepatitisC.•Awell-functioningchronicdiseasemanagementprogramshouldinclude:- Documentedindividualtreatmentplans- Casetracking(thefacilitydoesnotcurrentlyknowwhohaschronic

disease)- Adherencetowidelyacceptedcommunitystandards- Routinescheduledfollowupwithqualifiedhealthprofessionalsincluding

specialistswhereindicated

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14. TimelyAccesstoCare:Findings:•TheSantaBarbaraCountyJailisnotconsistentlyprovidingtimelyaccesstocareforseriousmedicalconditions.

•Timelyaccesstonursing–Areviewofrecordsshouldinconsistentresponse

timestorequestsformedicalcare,rangingfromsamedaytofourorfivedays.

•Timelyaccesstofacilityphysicians-Acrossthesystem,Idocumentedunacceptablylongwaitstoseeaphysician,withtypicalwaitsrangingfromfivedaystotwomonthsormore.Forthemostpart,thisappearedtoberelatedtolimitedstaffingofphysicianproviders.Inothercaseswherephysicianavailabilityhasbeenimproved,itappearedtobesimplyanestablishedinformalstandardbasedonpastpractice.(J-A-01)

•Timelyaccesstospecialtycare-TheSantaBarbaraCountyJailisnotprovidingtimelyaccesstospecialtycareforpatientswithseriousmedicalconditions.(J-D-05)

Recommendation:•Timelyaccesstonursesandfacilityphysicians-TheDepartmentshouldadjuststaffinginordertoaccommodatetimelyaccesstocareconsistentwiththetimelyaccessbenchmarksestablishedbytheNCCHC.•Timelyaccesstospecialtycare–TheDepartmentshouldcontinuetoworkwiththecommunityproviderstoprovidemoretimelyaccesstospecialtycareforseriousmedicalproblems.(Thecommunitystandardfortimelinessisestablishedbytheentirecommunity,notbythestandardsetbydepartment’schosencommunitypartner).

15. LaboratoryandDiagnosticServices

Findings:•Labsnotbeingordered,orifordered,notdrawn,orinrareoccasionswhendrawnarenotfiled,notedandoractedupon,andalmostneversharedwiththepatient.Thiscreatesbothdelaysinaccesstocareanddiagnosis,butalsocreatesasubstantialrisktopatientsandliabilityforthecountywhenabnormallabresultsarenotactedon.(J-D-04)Recommendation:

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•Policiesandproceduresmustbedevelopedanddeployedtoensurelabsorderedbycliniciansaredrawninatimelymanner,andthattheresultsarereviewedbynursesandcliniciansinatimelymanner,andthattheresultsarecommunicatedtothepatientsinatimelymanner.

16. PhysicalDisabilityIssues

Findings:•TheSantaBarbaraCountyJailmakesminimalaccommodationsforinmateswithphysicaldisabilitiesandinmanycasestheaccommodationsareoverlyrestrictiveorinadequatetoaccommodatethedisability.(J-G-02andJ-G-10)•Theoldbuildingisnothandicapaccessible.Wheelchairsdon’tfitthroughsomecelldoorswherewheelchairdependentinmatesarehoused(requiringtheinmatetobecarriedortransferredinandthewheelchairmustbecollapsedfirst)andtherearemanyotherphysicalbarrierstodisabledinmates.Recommendation:

•Thedepartmentshouldfollowexpertconsultantadviceondevelopinglessrestrictiveapproachestodealingwithinmateswithdisabilities.

17. PharmacyServices

Findings:•Thereisarestrictiveformularywithalmostnomedicalnon-formularyrequests.Thereweremultiplerequestsbythepsychiatristfornon-formularymedications(mostapprovedinrecentweeks),butthemedicaldoctoralmostneverrequestedanon-formularymedication.Thissuggestsanoverlyrestrictiveapproachtotheformularybeyondwhatisreasonable.•Ifoundrestrictedofrescueinhalers(suchasalbuterol)andunder-diagnosisofasthma.•Ininmateinterviews,manyinmatescomplainedthatgabapentin,amedicationcommonlyusedforneuropathy,wasdiscontinuedwithoutanyconsultationbetweenthedoctorandthepatients.Reviewsofmultiplemedicalrecordsconfirmedthattherewasablanketdiscontinuationof

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gabapentinwithoutappropriateclinicalconsultationandindividualizedmedicaljustification.•ThefacilitymakeslittleuseofKeepOnPerson(KOP)medications.(J-D-01)Recommendations:

•Formularyadherenceshouldbelessrestrictiveandallowforthoughtfulindividualizedtreatmentplansbasedonsoundclinicalcriteria.

•Cliniciansshouldbeeducatedintheprocessofrequestingnon-formularymedicationswhenthereislegitimateandcompellingclinicaljustification.Thefailuretoeverrequestexceptionstoarestrictiveformularyisevidenceoflackofindividualizedcare.•ThedepartmentshouldliberalizetheuseofKeeponPersonmedications–especiallyforinhalersandmedicationsthatareavailableover-the-counterinthecommunity.

18. ContinuityofMedications

Findings:•Inmatesarrivingonprescriptionmedicationsoftenexperiencedelaysinthemedicationbeingorderedandadministered,sometimesthedelayisdaysorevenoveraweek.•AdraftCFMGpolicycallsforverifiedmedicationstobeorderedwhentheinmateisseen“atthenextavailablesickcall.”Thisisproblematic,especiallyconsideringthatprovidersickcalldoesnotoccureveryday.Recommendation:

•Thedepartmentshouldreviewprocedurestoremoveunnecessaryinterruptionsintimelyaccesstocare.•Inordertoavoidinterruptionsinnecessarymedicationsforserioushealthconditions,nursesshouldevaluatepatientswhoarrivewithprescribedmedications,acuteillnessandchronicconditionsandconsultwithaproviderinatimelymanner(includingovernightsandweekends)toordernecessarymedicationsasclinicallyindicated.

•Policiesmustbedevelopedandimplementedtoensurethatnecessaryandverifiedmedicationsfromthecommunityarecontinuedwithout

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interruption,andthatinmateswithunverifiedmedicationsforseriousconditionsareevaluatedbythenurseswiththesupportofon-callmedicalproviders.

19. Grievances

Findings:•Allfacilitiesexperienceahighlevelofgrievancesbyinmatesalleginginadequatecare.Alargenumberofthesegrievancesweresubstantiated.(J-A-11)

Recommendation:

•GrievancesshouldbecategorizedandanalyzedaspartofaContinuousQualityImprovementprocess.

20. Dental

Findings:•Dentalcarewhenprovidedappearstomeetminimalstandards,buttherearesignificantdelaysinaccesstosuchcare.(J-E-06andJ-E-12))Recommendation:

•DentalClinicsshouldbescheduledandstaffedtoallowfortimelyaccesstoappropriatedentalcare.

21. Segregation

Findings:•Standardsdictatethatinmatesheldinsegregationareevaluatedbybothmentalhealthandmedicalstaff.Nursingstaffreportedthattheydocheckoninmatesheldinsegregation,oftenwhentheyareonahousingunitdoingapillpass,butthedocumentationbothonlogsorinthemedicalrecordfailtodocumentthattheseimportantchecksarebeingperformedattherequiredintervals(adailycheckisrequiredforcompleteisolationinaone-mancell).ThisdoesnotmeettheNCCHCstandardforthemonitoringofinmatesinsegregation.(J-E-09)•Inaddition,thefacilityusesisolationcellsthatarehiddenaroundcornersandoutsideofanystafflineofsite.Thesecellsdonothavecamera

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monitoringoraincellcallbutton,placingtheoccupantathighriskshouldeitherself-harmoramedicalemergencyarise.Recommendation:

•Thedepartmentshouldestablishprocedurestoensurethatinmatesheldinisolationandsegregationhavedailyassessmentsbymedicalpersonnelandinstitutealoggingprocedureforthoseencounters.•Isolationcellsshouldhavelineofsiteobservationorincellmonitoredcamerasandanintercomorcallbutton.

22. Impactofahighsecurityenvironmentonhealthcare

Findings:•ItisimportanttonoteforcontextthattheSantaBarbaraCountyJailisarestrictivejailenvironment.Thereappearstobenomeaningfulstandardizedrisk-basedclassification.Whilethismayseemtoallowforsomeefficiencyforsecuritypurposes,suchrestrictiveconditionsofconfinementcreateunnecessarybarrierstocareandintroducesignificantinefficienciesandrisksinthedeliveryofhealthcare.Thisapproachseemsparticularlyharshandproblematicforinmateswhomaybedetainedinthesefacilitiesforlongerperiods,suchastheAB109population.•Manyinmatesareconfinedtotheircellsorcellblocksformostoftheirincarcerationperiod.(Theyareletoutfordailyshowersandtwiceaweekforrecreationtime.Thereappearstobeveryminimalprogrammingoreducationaltime).Theiraccesstohealthcarepersonnelislimitedbytheirlimitedmovementandreliesonapaperdriven“kite”systemforreportingahealthconcern.Theironlyotheralternativeistocalla“mandown”medicalemergency.•Conditionsthatareoverlyrestrictivecananddohaveimpactoninmatehealthandwell-beingandincreaserisksofadversehealthevents.Minimally,theycreatebarrierstoaccesstorequiredmedicalcare.Recommendation:•Thedepartmentshouldconsultwithotherjailfacilitiesinthestateandinthenationtolearnaboutlessrestrictivedetentionpracticesthatdonotcompromisefacilitysafetyandsecurity,particularlyforthoseinmatesexpectedtoremainincarceratedforlongerperiodsoftime.

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23. SecurityStaffinginSupportofMedicalServices

Findings:•Thereisinsufficientcustodystaffingtosupportthemedicalprogram.•Evenifmedicalservicesareadequatelystaffed,accesstothepatientsisentirelydependentonescortservicesprovidedbysecurity.Thisincludesbothinfacilityandoutoffacilityescortneeds.A2013consultantreportbyCroutandSidafoundinsufficientcustodialstaffingoverall,andinsufficientmedicalescortstaffinginparticular.•Insufficientcustodialstaffinginsupportofmedicalservicesremainsanissueatthetimeofmyvisitresultinginpreventablebarriersintimelyaccesstomedicalcareandveryinefficientuseofmedicalprofessionaltime.Doctorsandnurseareroutinelykeptwaitingforpatientstobetransportedortobeescortedtoareasofthefacilitythatrequirecustodialescortforstaff.Recommendation:

•Security/Custodialstaffingmustbeadjustedtofullysupportthemedicalprogram.

24. DischargePlanning

Findings:•PertheJFAReportandmyowninvestigation,thejaillacksafullydevelopedcomprehensiveprogramtoprepareinmateswithchronicmentalandmedicalconditionsfortheirreleaseandtransitionbackintothecommunity.

Recommendation:

•ConsistentwiththeJFAReportrecommendationstheCountyshouldimplementandexpandacomprehensivein-custodydischargeplanningprogramwithemphasisoninmateswhosufferfromchronicmentalhealthandmedicalconditionsincludingaddiction.

25. ReviewofInCustodyDeaths

Findings:

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•Iwasprovidedwithlimitedaccesstosomemedicalfilesofinmateswhohaddiedincustody.•Whiletheinformationprovidedwasnotcomplete(Iwasnotprovidedwithmedicalexaminerreportsinallcases,forexample)whatwasclearwasthatroutinereviewsofinmatedeaths(includinganadministrativereview,aclinicalmortalityreviewandapsychologicalautopsyifdeathwasbysuicide)arenotroutinelyandconsistentlybeingdone.Thisisamissedopportunitytoaddresscriticalproblemsandpreventfutureincidents.(J-A-10)

Recommendation:

•Routinedeathreviews(includingaquick,multi-disciplinaryadministrativedeathreview,aclinicalmortalityreviewandapsychologicalreviewifdeathwasbysuicide)shouldbedonewithin30daysofthedeath.

26. CountyMonitoringoftheMedicalContract

Findings:•SantaBarbaraCountyJailfailedtodeliveradequatemedicalcareinlargepartbecausethepreviousmedicalcontractorprovidedinadequatecare.•Whilereplacingthatproviderwithanewproviderwasanimportantcorrectivestep,theCountyisstilllargelyrelyingonthecontractortomeettheCounty’sconstitutionalobligationstoprovidecare.•Whiletheworkcanbecontractedout,theresponsibilityoftheCountyinprovidingminimallyacceptablemedicalcarecannot.•TheCountycurrentlydoesnotemployCountyresourcesnorexpertiseinprovidingoversighttothemedicalcontract.Inthe2016reportonrealignment,theconsultantsmadethefollowingrecommendation:

RequiretheDepartmentofPublicHealthandBehavioralWellnesstoAdministertheNewMedicalContractfortheSheriffRationale:TheSheriffisnottheproperagencytomonitoracontractthatdeliversmentalhealthservicesinthejail.TheCounty’sDepartmentsofPublicHealthandBehavioralWellnessshouldadministerthecontracttoensureinmatesarebeingproperlyassessedandtreatedinthejail,andtoensurethetransitionfromthejailtothecommunitydoesnotinterrupttheservicesthatwerebeingprovidedinthejail.

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Recommendation:•TheCountymustunderstanditsresponsibilityinmonitoringthemedicalcontractonaday-to-daybasis.ItshouldconsiderhiringconsultantorusingexistingCountyemployedexpertisetoaccomplishthiscriticaloversitefunction.Consistentwithpriorconsultantrecommendations,theCountyshouldexplorethepossibilityofrequiringtheDepartmentofPublicHealthandBehavioralWellnesstoadministerthenewmedicalcontractfortheSherifforalternatively,createanewpositionforaqualifiedindividualwithappropriateexpertiseandexperiencetoperformthatrole.•Medicalcare,acriticalcomponentofconstitutionallyguaranteedrightsoftheincarcerated,istoogreataresponsibilitytocontractoutentirely.ExpertandCountybasedoversiteofthiscomplexprogramisinthebestinterestsoftheCountyanditscitizens.

Summaryof2014NCCHCJailStandardsNotBeingMetorRequiringFurtherWorkThefollowingismysummaryofpriorityareasthatthedepartmentshouldcontinuefocusoninordertobereadyforNCCHCaccreditation:J-A-01AccesstoCareJ-A-05PoliciesandProceduresJ-A-06ContinuousQualityImprovementPlanJ-A-09PrivacyofCareJ-A-10ProcedureintheEventofanInmateDeathJ-A-11GrievanceMechanismforHealthComplaintsJ-B-01InfectionPreventionandControlProgramJ-C-01CredentialsJ-C-02 ClinicalPerformanceEnhancementJ-D-01PharmaceuticalOperationsJ-D-03ClinicSpace,Equipment,AndSuppliesJ-D-05HospitalandSpecialtyCareJ-E-02ReceivingScreeningJ-E-04 InitialHealthAssessmentJ-E-07Non-EmergencyHealthCareRequestsandServicesJ-E-09SegregatedInmatesJ-E-12ContinuityandCoordinationofCareDuringIncarcerationJ-G-01ChronicDiseaseServicesJ-G-02PatientswithSpecialHealthNeedsJ-I-01RestraintandSeclusion

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RespectfullysubmittedtoCounselfortheCountyofSantaBarbaraandtheCounselforthePlaintiffsonJuly3,2017.

ScottA.Allen,MD

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AppendixExamplesofinadequaciesinchronicdiseasemanagement:

Asthma-Asthmacareinthecasesrevieweddoesnotmeetnationallyacceptedstandards.ThefacilitymakesnouseofPeakflowmeters.Peakflowmetersareinexpensiveplasticdevicesthatallowforreliableobjectiveassessmentoftheseverityofapatient’sabilitytobreathandareconsideredastandardpartofasthmamanagement.Insomecasesreviewed,patientswithsignificantasthmahistorieswerenotevaluatedbyphysiciansunlesstheypresentedwithanacuteattack.Evenwiththenewmedicalcontractor,useofkeeponpersoninhalerswasbeingrestricted,withinmateswithdocumentedasthmahistoriesbeingdirectedtocontactnursingonlywhentheythoughttheyneededtouseaninhaler.Thisisariskyandunnecessarilyrestrictivepractice. Diabetes-Diabetescareatthejailfacilitiesisinconsistent.Knowndiabeticsdotypicallyreceiveadequatemonitoringbynurseswithassessmentofbloodsugarbyfingersticktestingasorderedbyaphysician.However,regularevaluationbyaphysicianisinconsistent.MeasurementofHemoglobinA1C(HgbA1C–astandardmeasureofdiabeticcontrol)onarrivalandatrecommendedintervals(typicallyevery90days)isinconsistent.Inaddition,patientsenteringthefacilitywithconfirmedtreatmentregimensdonothavetheircommunitytreatmentcontinued.Rather,theyareoftenautomaticallychangedovertoagenericslidingscaleinsulinprotocoluntiltheycanbeseenbyaprovider,oftennotuntildaysafterarrival.Slidingscaleinsulinisnottheoptimalprimarymethodofmanagingdiabetesparticularlywhenapatienthasaconfirmedmedicationregimenfromthecommunity. Hypertension-ManagementofhypertensionintheSantaBarbaraCountyJaildidnotmeetnationallyacceptedguidelinesforthecasesIreviewed(Ref:NCCHCOctober2014guidelinesforhypertension,JNC8).Specifically,patientswithhypertensiondidnottypicallyreceivecompleteinitialexamsandwork-ups,theydidnotconsistentlyreceiveappropriatelaboratoryorEKGtests.InseveralcasesIreviewed,theinmateswentthreetofourdayswithoutmedications.HIV-HIVcareintheSantaBarbaraCountyJaildoesnotmeetnationallyacceptedguidelinesincludingtimelyconsultationbyamedicalconsultantwithexpertiseinHIVmanagement.Otherchronicconditions-Inothercaseswhereinmateshadknownchroniccareneeds(includingconditionssuchascoronaryarterydisease,

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neuropathy,gynecologicproblems,chronicorthopedicproblems)carewasinfrequentandcavalier.

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