IN THE UNITED STATES DISTRICT COURT 
 FOR THE DISTRICT OF NEW MEXICO 


UNITED STATES OF AMERICA

)

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Plaintiff,

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v.

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SANTA FE COUNTY,

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SANTA FE COUNTY ADULT

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DETENTION CENTER,

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ANNABELLE ROMERO, Corrections )

Director,

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DAVID TRUJILLO, Jail

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Administrator,

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THE BOARD OF COUNTY

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COMMISSIONERS OF

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SANTA FE COUNTY,

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Defendants.

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______________________________

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CIV 08-212 MCA/RHS

SETTLEMENT AGREEMENT

I. INTRODUCTION 1. On March 20, 2002, the United States, through the Department of Justice (“DOJ”),
notified Santa Fe County officials of its intention to investigate conditions of confinement at the Santa Fe County Adult Detention Center (“SFCADC” or “the Detention Center”), pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997.

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2. On May 7-10 and 29-31 2002, the United States conducted investigatory tours of SFCADC with consultants in the fields of correctional health care, correctional mental health care, Detention Center security and safety, and employee training and supervision.
3. On March 6, 2003, the United States issued a findings letter pursuant to 42 U.S.C. § 1997 that concluded that certain conditions at SFCADC violate the constitutional or statutory rights of individuals confined at the Detention Center. The County denied, and continues to deny, that conditions at SFCADC violate the constitutional or statutory rights of individuals confined at SFCADC.
4. On November, 1, 2004, Santa Fe County and its elected officials, employees, agents, and contractors responsible for the operation of SFCADC and the United States entered into a Memorandum of Agreement (“MOA”) to resolve the United States’ CRIPA investigation and ensure constitutional conditions of confinement at SFCADC. The MOA terminated by its own terms on October 31, 2007.
5. Following execution of the MOA, the United States and its expert consultants conducted compliance tours in March 2005, July 2005, February 2006, August 2006, and March 2007. The United States issued detailed, written compliance assessments to the County on July 14, 2005, July 24, 2006, January 12, 2007, and July 6, 2007.
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6. As the County is not yet in substantial compliance with all provisions of the MOA, the parties have agreed to enter into this Agreement.
II. GENERAL PROVISIONS 7. This Settlement Agreement (the “Agreement”) is entered into between the United States
and SANTA FE COUNTY, SANTA FE COUNTY ADULT DETENTION CENTER, ANNABELLE ROMERO, Corrections Director, DAVID TRUJILLO, Jail Administrator, and THE BOARD OF COUNTY COMMISSIONERS OF SANTA FE COUNTY; and their successors, contractors, and agents (collectively, the “County”).
8. The Agreement resolves the investigation conducted by the United States at SFCADC pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. The Agreement addresses the corrective measures set forth by the United States in its March 6, 2003 findings letter to the County and subsequent assessments of the County’s compliance with the MOA on July 14, 2005, July 24, 2006, January 12, 2007, and July 6, 2007. This Agreement replaces the MOA. This Agreement does not serve as an admission by the County that corrective measures are necessary to meet the constitutional and statutory rights of inmates at SFCADC.
9. In conformity with CRIPA, this Agreement represents a voluntary effort by the County to meet the concerns raised by the United States’ investigation. See 42 U.S.C. § 1997b (a)(2)(B) and § 1997g. −3−


10. Pursuant to 42 U.S.C. § 1997b(a)(2)(B) and § 1997g, the United States agrees to support the County’s application for federal funding conditioned upon the County’s proper implementation of the suggested remedial measures.
11. Nothing in this Agreement shall be construed as an acknowledgment, an admission, or evidence of liability of the County under CRIPA, the Constitution or federal or state law, and this Agreement may not be used as evidence of liability in this or any other civil or criminal proceeding.
12. The signatures below of officials representing the United States and the County signify that these parties have given their final approval to this Agreement.
13. This Agreement is enforceable only by the parties or, upon motion by a party to enforce terms of this Agreement, by the Court. This Agreement is binding upon the parties, by and through their officials, agents, employees, and successors. No person or entity is intended to be a third party beneficiary of the provisions of this Agreement for purposes of any civil, criminal, or administrative action, and, accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Agreement in any civil, criminal, or administrative action. Similarly, this Agreement does not authorize, nor shall it be construed to authorize, access to County documents by persons or entities not a party to this Agreement. This Agreement is not intended to impair or expand the −4−


right of any person or organization to seek relief against the County or its officials, employees, or agents for their conduct. This Agreement does not alter legal standards governing any such claims, including those standards established by New Mexico law.
14. This Agreement shall constitute the entire integrated Agreement of the parties. With the exception of the March 6, 2003 findings letter, no prior contemporaneous communications, oral or written, or prior drafts shall be relevant or admissible for purposes of determining the meaning of any provisions herein in any litigation or any other proceeding. Both parties acknowledge that the findings set forth in the March 6, 2003 letter will not be admitted for purposes of establishing conditions at the Santa Fe County Adult Detention Facility, but the defendant agrees to its admission to establish that the United States notified the defendant of its experts’ opinions about the specific conditions of the facility identified in that letter. Any amendment to this Agreement shall be in writing and signed by both parties.
15. Since the United States issued its last compliance assessment on July 6, 2007, the County has made progress in remedying the problems the United States identified in the March 6, 2003 findings letter and subsequent compliance assessments. The parties agree that it is in their mutual interests to avoid litigation. The parties further agree that resolution of this matter pursuant to this Agreement is in the best interests of SFCADC inmates. Now, therefore, pursuant to Fed. R. Civ. P. 41(a)(2), the parties hereby agree to file this Agreement in the United States District Court for the District of New Mexico, together −5−


with a Complaint and a motion to conditionally dismiss the Complaint under the conditions set forth in this Agreement. The parties further agree that this case will remain on the Court’s inactive docket during the term of, and subject to, this Agreement, and that, from time to time, the Court may hold, at the request of either party, status conferences for the sole purpose to assist the parties to informally resolve disputes, if any, until this Agreement terminates.
16. All parties shall bear their own costs, including attorneys’ fees, in this and any subsequent proceeding.
17. This Agreement shall take effect on November 1, 2007.
18. The County shall ensure that all Santa Fe County Departments take any actions necessary to comply with the provisions of this Agreement.
19. The Court has jurisdiction over this action pursuant to 28 U.S.C. § 1331, 28 U.S.C. § 1345, and 42 U.S.C. § 1997. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
III. DEFINITIONS 20. “SFCADC” or “the Detention Center” shall refer to the Santa Fe County Adult Detention
Center, sometimes called the Santa Fe County Correctional Facility, which is currently located at 4312 New Mexico Highway 14, Santa Fe, New Mexico, as well as any facility
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that is built, leased, or otherwise used, to replace or supplement the Detention Center. “SFCADC” does not include alternatives to incarceration such as off-site drug and alcohol treatment centers, detoxification centers, outside mental health treatment facilities, electronic monitoring programs, facilities for the incarceration of minors, or work release centers.
21. “DOJ” shall refer to the United States Department of Justice, which represents the United States in this matter.
22. “The County” means Santa Fe County and its elected officials, employees, agents, and contractors responsible for the operation of and provision of services at the Detention Center.
23. “Court” or “the Court” means the United States District Court for the District of New Mexico.
24. “Include” or “including” shall mean “include, but not be limited to” or “including, but not limited to.”
25. “Inmate” or “inmates” shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at either the existing
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Detention Center or any institution that is built or used to replace the Detention Center or any part of the Detention Center.
26. Consistent with, or in accordance with, the term “generally accepted professional standards of care” shall mean a decision by a qualified professional that is substantially aligned with contemporary, accepted professional judgment, practice, or standards as to demonstrate that the person responsible based the decision on such accepted professional judgment.
27. “Quality Assurance” means a system of self-audit and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Agreement, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
28. “Effective date” shall mean November 1, 2007.
29. “Health services staff” means any and all healthcare staff, who by virtue of license, credentials and/or training, provide health services at the Detention Center.
30. “Inmates with chronic disease” shall include, but are not limited to, those inmates who have been diagnosed with diabetes, hypertension, asthma, cardiac disease, Human
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Immunodeficiency Virus (“HIV”) infection, viral hepatitis, and seizure disorder, and may include inmates with other chronic diseases.
31. “Medical staff” means licensed physicians, licensed physician’s assistants, and licensed nurse practitioners employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those health services she or he has undertaken to provide.
32. “Mental health professional” means an individual employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those mental health services she or he has undertaken to provide.
33. “Nursing staff” means licensed registered nurses (“RNs”) and licensed practical nurses (“LPNs”) employed at the Detention Center employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those health services they have undertaken to provide. It does not include nurse’s aides, certified nursing assistants, or EMTs.
34. “The parties” means the County and the United States.
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35. “Train,” when the term is used in remedial provisions of this Agreement, means adequately instruct in the skills addressed, including assessment of mastery of instructional material.
36. Throughout this Agreement, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance. “Substantial compliance” indicates that the Detention Center has achieved compliance with most or all components of the relevant provision of the Agreement. “Partial compliance” indicates that compliance has been achieved on some of the components of the relevant provision of the Agreement, but significant work remains. “Non-compliance” indicates that most or all of the components of the Agreement provision have not yet been met.
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IV. SUBSTANTIVE PROVISIONS
 A. MEDICAL AND MENTAL HEALTH CARE Standard 37. Serious Medical and Mental Health Needs. The County shall provide adequate services
to address the serious medical and mental health needs of all inmates.
Medical and Mental Health Staffing and Professional Credentials 38. Medical Director The medical director of the Detention Center shall be a qualified,
licensed physician, shall supervise all clinical practices and medical policy development at the facility, and shall communicate problems and resource needs to the Jail Administrator. The medical director of the Detention Center shall have ultimate responsibility for supervising clinical decision-making.
39. Psychiatrist Staffing The County shall retain a psychiatrist for a sufficient number of hours per week to see patients, prescribe psychotropic medications, develop individualized treatment plans for inmates with serious mental health needs, supervise care provided by other mental health practitioners at the facility, review charts, review the results of diagnostic and laboratory tests, and review policies, procedures, and protocols. The psychiatrist shall take a lead role in mental health services management as well as clinical treatment, shall communicate problems and resource needs to the Jail Administrator, and shall serve as the ultimate clinical authority at the facility for mental health care. −11−


40. Physician Staffing Physician staffing shall be sufficient to provide adequate care for patients, review policies, procedures and protocols, supervise care provided by lower level practitioners including chart review, and participate in quality improvement and infection control programs.
41. Health Services Staffing Health services staffing levels shall be sufficient to provide adequate treatment for inmates’ serious medical and mental health needs by qualified and trained health services and mental health professionals. Appendix A sets forth the required staffing minima for registered nurses, psychiatrist, physician, and other medical and mental health staff.
42. Scope of Practice All persons providing medical or mental health care shall meet applicable state licensure and/or certification requirements. Health services staff shall not practice outside the scope of their licensure and training. Upon hiring and annually, SFCADC shall verify that all health services staff has current, valid, and unrestricted professional licenses.
43. Health Services Staff Training The County shall train medical and mental health staff sufficiently to perform their duties at the Detention Center in accordance with this Agreement. This training shall include guidance to ensure that staff does not practice
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outside the scope of their licensure, and that they refer inmates with serious medical and mental health needs for care by those qualified to treat such needs.
44. Correctional Officer Identification of and Response to Urgent Medical and Mental Health Needs The County shall implement policies and procedures for correctional officers to refer inmates who exhibit signs and symptoms of urgent medical or mental health needs including intoxication and withdrawal for appropriate medical or mental health attention. The County shall make best efforts to train all correctional officers who work with inmates to provide first aid-responder assistance in an emergency situation (CPR, valve resuscitation and how to address serious bleeding). The County shall ensure that trained staff is available to respond in a timely fashion to any medical emergency at the facility. The County shall provide all personnel who have inmate contact with the necessary protective gear (including rubber gloves and protective mouth shields) to provide first line emergency response. The County shall train all correctional officers who work with inmates to understand and identify signs and symptoms of drug and alcohol withdrawal and recognize other medical and mental health urgencies.
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Intake Medical and Mental Health Screening, Referral and Assessment 45. Privacy The County shall provide for an inmate’s reasonable privacy in medical and
mental health care, and maintain confidentiality of inmates’ medical and mental health status, subject to legitimate security concerns and emergency situations.
46. Intake Clinical Health Screening The County shall provide for intake clinical health screening by health services staff for new inmates and inmates transferring from other correctional institutions in a reasonably private setting at the time of booking. For this intake health screening, health services staff shall record and seek the inmates’ cooperation to provide: (1) medical, surgical, and mental health history, including current or recent medications; (2) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use; (3) history of substance abuse and treatment; (4) pregnancy; (5) history and symptoms of communicable disease; (6) suicide risk history; and (7) history of mental health treatment, including medication and hospitalization. Inmates who screen positively for any of these items shall be referred to the medical unit for immediate treatment or for referral at a reasonable time, as appropriate. Staff shall attempt to elicit the amount, frequency and time of the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. The County shall ensure that staff performing initial health screenings is trained to complete the assessments. This initial health screening information shall promptly become part of an inmate’s medical record.
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47. Observation of Inmates Upon Intake Correctional officers supervising newly arrived inmates shall physically observe the conduct and appearance of these inmates to determine whether they have a more immediate need for medical or mental health attention prior to or following their intake health screenings by health services staff.
48. Unified Medical Record Staff shall retrieve all retrievable medical and mental health records from an inmate’s previous period of incarceration at the Detention Center (where the record can be positively matched to the inmate) prior to the inmate’s next medical or mental health encounter after the clinical health screening, and shall consolidate them with the inmate’s current medical record. The County shall maintain unified medical, dental and mental health records. All records shall be timely filed in patients’ medical charts. For purposes of this Agreement, “timely filed” means within ten (10) days of receipt, review, creation, or use, except for medication administration records (see provision 71), which shall be filed within ten (10) days of the end of a month. Laboratory reports shall be timely reviewed by the appropriate health services staff, filed within three (3) days of receipt, and noteworthy results reported to inmates as medically appropriate. In the event the County moves to an electronic medical record, that system will conform to the concepts set forth in this provision recognizing that the process of electronic medical record keeping may differ slightly from the process set forth above.
49. Outside Medical Records For inmates with chronic diseases, pregnancy or mental illnesses, if a member of the medical staff or a mental health professional requests −15−


retrieval of outside medical records, the County shall request a release of information from the inmate and if granted, shall send a request for the inmate’s treatment records to current treatment providers identified by the inmate within two days.
50. Tuberculosis (“TB”) Testing As part of the fourteen day health assessment, the County shall routinely screen all inmates for symptoms or risk factors for TB. Pursuant to Centers for Disease Control (“CDC”) Guidelines, if health services staff determine that an inmate is at risk for TB, SFCADC will perform a tuberculin skin test (i.e. Mantoux “PPD”), unless such test is unnecessary (i.e. history of prior positive tests) or medically contra-indicated. The County shall read the PPD forty-eight (48) to seventy-two (72) hours after placement of the PPD. Within 72 hours of determining that an inmate’s PPD test is positive, the County shall schedule an appointment for a chest x-ray of the inmate. The County shall ensure that inmates are transported to the scheduled appointment. The County shall follow CDC guidelines in effect on the date this Agreement is executed, for management of inmates with TB infection, including providing prophylactic medication when medically appropriate, or shall follow screening and assessment guidelines set forth by the New Mexico Department of Health, as appropriate. The County will consider implementing subsequently revised CDC guidelines. Inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and housed in the health services unit until they may be transferred to another facility or location where respiratory isolation is available. The facility shall
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provide for infection control and for the safe housing and transportation of such inmates.
51. Screening, Testing and Treatment of Communicable Diseases The County shall implement a policy for STD screening, testing, and treatment that is consistent with the standards of the New Mexico Department of Health and appropriate to the inmate population of the Detention Center. The policy shall be implemented within 120 days of the date this Agreement is executed.
52. Continuity of Medication at Intake The County shall implement a medication continuity system so that incoming inmates’ medication for serious medical needs can be obtained in a timely manner, as medically appropriate when medically necessary. Within twentyfour hours of an inmate’s arrival at the facility, or sooner if medically necessary, the County shall decide whether to continue the same or comparable medication for serious medical needs as an inmate reports on arrival that she or he has been prescribed. If the inmate’s reported medication is discontinued or changed by medical staff, medical staff shall evaluate the inmate face-to-face as soon as medically appropriate. The County shall implement a protocol and screening tool to guide health services staff in gathering necessary information and present such information to medical staff for medication continuity decisions.
53. Expedited Referral for Medical and Mental Health Needs When the initial clinical health screening indicates that an inmate has acute health or mental health needs, the County −17−


shall provide timely care by trained and licensed medical staff, registered nurses, or mental health professionals as soon as medically necessary, within the recommended timeframe as set out by the evaluating health professional (a nurse practitioner, physician’s assistant, or physician). The County shall schedule individuals with chronic health or mental health needs and those who are pregnant but who present in a stable condition to be seen by medical staff or mental health professionals as soon as medically necessary. Incoming inmates who present with current risk of suicide or other acute mental health needs will be immediately referred for a mental health evaluation by a mental health professional. Staff will observe such inmates until they are seen by mental health professionals. Incoming inmates reporting these conditions will be housed under appropriate conditions in the Health Services Unit unless and until a mental health care professional clears them for housing in segregation or with the general population.
54. Fourteen Day Health Assessment The County shall perform a screening physical and mental health assessment for each inmate within fourteen (14) days of an inmate’s arrival at the Detention Center, unless the County knows that an inmate will be incarcerated for fewer than thirty (30) days. For inmates incarcerated for fewer than 30 days, the County shall conduct the testing required by provision 50. The assessment shall include a comprehensive medical history, physical examination, mental health history, and current mental health status examination. Qualified health services staff may gather health history and vital signs from an inmate. The physical examination shall be conducted by medical staff or registered nurses. Records documenting the assessment and results shall −18−


become part of each inmate’s medical record. A re-admitted inmate or an inmate transferred from another facility who has received a documented full health assessment within the previous three months and whose receiving screening shows no change in the inmate’s health status need not receive a new full physical health assessment. For such inmates, qualified personnel shall review prior records and update tests and examinations as needed.
55. Comprehensive Mental Health Evaluation The County shall ensure that any inmate who screens positively for mental illness, suicidal ideation, or other mental health needs during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services receives a comprehensive mental health evaluation from a mental health professional licensed and trained to diagnose, within twenty four (24) hours of referral for an expedited comprehensive evaluation, or seventytwo (72) hours of referral for a routine comprehensive evaluation. The comprehensive mental health evaluation shall include a recorded diagnosis section, including a standard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If mental health staff finds a serious mental illness, they shall treat appropriately. The County shall review available information regarding any diagnoses made by the inmate’s community or hospital treatment provider.
Access to Medical and Mental Health Services
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56. Access to Medical and Mental Health Services Initial paper screening of medical and mental health care request slips (or electronic records if an electronic medical record is implemented at the facility) shall be conducted within twenty-four (24) hours of health services staff’s receipt and may be conducted by an LPN or EMT. All inmates who submit medical care request slips indicating the need for clinical judgment and/or physical assessment shall be seen by medical staff or registered nurses as soon as medically necessary. Registered nurses performing acute care shall be guided by physician approved nursing protocols that are updated annually, and shall consult with or refer patients to the on-call medical staff as appropriate. Medical care requests that do not indicate the need for clinical judgment and/or physical assessment may be handled by LPNs. The County shall implement a protocol guiding the distinction between those medical care request slips that require face-to-face services and those that do not. Written requests for mental health services shall be forwarded to a mental health professional and timely evaluated by him or her. Notwithstanding the foregoing, the health services worker forwarding sick call slips to mental health providers shall respond to any apparently emergent need in accordance with provisions 59 and 60.
57. Acute care policies, procedures and practices The County shall ensure that its acute care policies, procedures, and practices address and guide the following: (1) written medical and mental health care request slips available in English and Spanish; (2) a confidential collection method in which the request slips are collected by health services staff seven days per week; (3) a logging procedure to record the date and summary of each request −20−


for acute care, the date the inmate was seen and the name of the person who saw him or her, the disposition of the medical or mental health visit (e.g., referral; whether inmate scheduled for acute care visit), and if follow up care is necessary, the date and time of the inmate’s next appointment; (4) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; (5) opportunity for all inmates, irrespective of primary language, to access medical and mental health care; and (6) recording of results of the medical or mental health care request in the inmate’s medical record.
58. Rounds Mental health professionals shall make monthly rounds in the housing units to identify inmates who may have mental health needs but who have not accessed mental health services through the sick call system.
59. Expedited Referral The County shall ensure that inmates requesting mental health services, inmates who become suicidal, inmates who are referred for mental health services by correctional officers, and inmates who develop serious mental illness while incarcerated, are evaluated and treated timely, irrespective of the manner in which the services are requested. Mental health professionals shall be provided with up-to-date housing lists of inmates to ensure continuity of care.
Emergency Care
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60. Response to Emergencies The County shall train correctional officers to recognize and respond to medical and mental health emergencies and shall ensure that inmates with emergency medical or mental health needs receive timely and appropriate care within the facility, and are promptly referred and transported for outside care when the facility is unable to provide appropriate care.
Continuity of Care and Access to Outside Providers 61. Recovering Inmates and Inmates Unable to Care for Themselves The County shall
ensure that inmates who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. All inmates returning to the facility after surgery or hospital treatment and inmates who cannot care for themselves shall be seen immediately by medical staff and placed or treated as medically appropriate upon return to the facility.
62. Access to Specialty Care The County shall ensure that inmates whose serious medical or mental health needs go beyond the services available at the Detention Center shall receive timely referral to appropriate medical or mental health care professionals qualified to meet their needs. The County shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. Inmates awaiting outside care shall be seen by medical staff as medically necessary to evaluate the current urgency of the problem and respond as medically appropriate. The −22−


County shall seek to obtain records of care and diagnostic tests received during outside appointments in a timely fashion and include such records in the inmate’s medical record or document the inmate’s refusal to cooperate and release medical records. Following a visit to an outside specialist, medical staff, mental health staff, or a dentist shall review information and documentation available from the visit and provide reasonable follow-up care.
63. Mental Health Services Log The County shall maintain an updated log of inmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive medication. The log shall include each inmate’s name, diagnosis or complaint, and next scheduled appointment.
Chronic Diseases 64. Clinical Guidelines The County shall develop or adopt existing written updated clinical
guidelines for chronic diseases, consistent with nationally accepted guidelines, and implement such guidelines to provide appropriate diagnosis, monitoring, treatment and continuity of care.
65. Chronic Disease Log The County shall maintain an updated log of inmates with chronic illnesses. The County shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmate’s individual medical record.
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Treatment of Female Inmates 66. Treatment Guidelines The County shall implement nursing protocols concerning medical
care for women, including screening for pregnancy, and gynecological and obstetric care. The County shall implement timely and appropriate care for pregnant women as medically indicated, including discharge planning. The County will work with and refer pregnant inmates to community providers capable of developing individual treatment plans and assisting with discharge planning. In such cases, the County shall facilitate treatment planning and implement those responsibilities assigned to the County under the plan subject to reasonable security considerations.
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Drug and Alcohol Withdrawal and Detoxification 67. Drug and Alcohol Withdrawal Identification and Treatment The County will screen all
incoming inmates for signs and symptoms of drug and alcohol withdrawal and ensure that all inmates demonstrating symptoms of drug and alcohol withdrawal are timely identified. The County shall provide appropriate treatment, housing and medical supervision for drug and alcohol withdrawal.
Medication Management 68. Access to Appropriate Medication The County shall ensure that inmates have timely
access to necessary medications for known serious medical or mental health conditions. The County shall develop and implement a plan to ensure that off-formulary medications may be requested, approved, received, and administered within a reasonable period after determination by medical staff that such medication is medically necessary to treat a serious medical or mental health condition. The plan shall include a provision for expedited access to and administration of off-formulary medications when medically necessary. During the term of this Agreement, the County shall log all requests for approval of off-formulary medications, the dates of the request and approval or denial, the reasons for any denial, and the date the inmate began receiving the medication.
69. Delivery and Continuity The County shall ensure continuity of medication by ensuring regular and timely distribution and documentation of medication to all inmates, including: access to medication in emergencies and on weekends; contemporaneous −25−


documentation and monitoring of dosages dispensed and received and documentation of refusals and no-shows; timely recording of medication records in patients’ individual files; and recording and monitoring of medication errors. The County shall track refusals of medication and no-shows to be reviewed in its quality assurance program, and shall take appropriate corrective measures if the review evidences problems in medication distribution.
70. Prescribing Practices Only qualified medical staff shall prescribe medications. The only exceptions shall be following written protocols for immunizations or life-threatening emergencies. Except for renewals, inmate patients shall have a face-to-face evaluation by the prescribing clinician or designated health professional with prescriptive authority, within seventy-two (72) hours of the telephone prescription order, for medications prescribed for serious medical or mental health illnesses or symptoms.
71. Medication Administration Records The County shall provide for complete patientspecific medication administration records for all individually administered medications. For keep-on-person medications, the County shall record delivery of the medication. The County shall document inmates’ refusal to take individual dose prescription medication or receive keep-on-person medication.
72. Discharge Medication and Information When the County has advance notice of the discharge of inmates with serious medical or mental health needs from detention, the −26−


County shall provide such inmates with at least a seven (7) day supply of appropriate prescription medication, unless a different amount is medically appropriate, to serve as a bridge until inmates can arrange for continuity of care in the community. The County shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. The County shall prepare and send with transferring inmates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Detention Center. The County shall ensure that information about potential release or transfer of inmates is communicated to health services staff as soon as it is available to the County.
Mortality Reviews 73. Autopsy The County shall request an autopsy for every inmate who dies while in the
custody of the Detention Center.
74. Mortality and Morbidity Reviews The County shall conduct a mortality review for each inmate death while in custody and a morbidity review for all serious suicide attempts or other incidents in which an inmate was at high risk for death. Mortality and morbidity reviews shall involve physicians, nurses, and other relevant Detention Center personnel and shall seek to determine whether there was a pattern of symptoms which might have resulted in earlier diagnosis and intervention. The mortality and morbidity reviews shall analyze the circumstances surrounding the incident. The County shall obtain any autopsy −27−


reports and related medical data or shall document the unsuccessful attempts to obtain them. The County shall address any problems with care or access to care that occurred, through training, policy revision and any other appropriate measures.

Infection Control 75. Infection Control Plan The County shall implement an infection control program that
addresses blood borne and airborne hazards and infections spread through contact. The plan shall include provisions for the identification, treatment, and control of Methicillinresistant Staphylococcus Aureus (“MRSA”) at the Detention Center.

76. Training The County shall train staff and inmate workers regarding measures necessary to prevent the spread of blood borne and airborne pathogens and infections spread through contact.

77. Hazardous waste The County shall appropriately dispose of hazardous and medical waste.

78. Laundry The County shall implement generally accepted environmental health standards for institutions for laundering inmates’ clothing and linens in a manner that prevents spread of infection, including proper use of disinfectant.

B. SUICIDE PREVENTION

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79. Policy The County shall revise existing suicide prevention policies as necessary to include: (1) staff training; (2) identification and screening of potentially suicidal inmates; (3) appropriate housing for suicidal inmates; (4) effective watch procedures, durations and conditions of monitoring; (5) suicide intervention procedures; and (6) receipt and transmission to appropriate persons of reports of inmate suicidal behavior and information needed to protect suicidal inmates.
80. Training The County shall train clinical, mental health and correctional officer staff who have inmate contact regarding: (1) the warning signs and symptoms of inmates at risk of suicide; (2) why correctional environments are conducive to suicidal behavior; (3) highrisk suicide periods; (4) potential predisposing factors to suicide; (5) procedure and methods for responding to inmates who exhibit such risk; (6) observation techniques; (7) searches of inmates who are placed on suicide watch; (8) emergency procedures for responding to a suicide attempt; (9) location and use of cut-down tools and other emergency response supplies; and (10) how to refer inmates with mental health needs for appropriate care. All facility staff that has inmate contact shall have initial training and refresher trainings annually.
81. Suicide Watch The County shall revise as necessary policy, procedures and practices to ensure that inmates placed on suicide watch are supervised sufficiently to maintain their safety and to address the following requirements. When staff initially places an inmate on observation, the inmate shall be strip searched and monitored until a mental health −29−


professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. On a case-by-case basis, it may be acceptable to order the housing of two suicidal inmates in the same cell. Until such assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients. Mental health staff shall provide services initially as soon as possible and then as medically appropriate to all inmates on suicide watch Monday through Friday. Mental health trained registered nurses may provide this function on weekends. On-call mental health staff shall respond as necessary to provide care to inmates newly placed on suicide watch on the weekends. Inmates shall only be removed from suicide watch after approval by mental health staff after a suicide risk assessment indicates it is safe to do so. Mental health staff shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. The County shall revise observation logging procedures and practices to ensure that sufficiently detailed information about an inmate’s suicide watch is recorded at appropriate intervals. At the time of placement on suicide watch, medical or mental health staff shall write orders setting forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils. These conditions shall be altered only on the written instruction of the mental health staff, except under emergency circumstances.
82. Risk Assessment The County shall ensure that any inmate showing signs and symptoms of suicide is assessed using an appropriate suicide risk assessment instrument.
−30−


C. SECURITY AND SAFETY Inmate Supervision 83. Correctional personnel The County shall staff the master control center; each housing
unit, including administrative and disciplinary segregation; booking; the kitchen area and the medical area with adequate correctional personnel to protect inmates from unreasonable risks of harm. At all times, the master control center shall be staffed by at least two correctional officers and each housing unit control center shall be staffed by at least one correctional officer. Staff may be aided by appropriate monitoring equipment maintained in working order.
84. Monitoring equipment The County shall maintain in working order all monitoring equipment at the Detention Center.
Grievances and Investigations 85. Filing of grievances The County shall develop and implement an effective inmate
grievance system, ensure that grievances may be filed confidentially where the filing of such grievance might expose the inmate or a third party to imminent danger. The County shall also ensure that grievances receive appropriate follow-up, including informing the grievant of its outcome and tracking implementation of resolutions.
86. Investigations The County shall develop and implement policies, procedures and practices regarding internal investigations to ensure that management has a mechanism −31−


for identifying problems and appropriate remedies. The County shall maintain staffing sufficient to meet such internal investigation responsibilities.
Booking Area 87. Safety The County shall provide for the safety and security of inmates in the booking
area. The booking area shall not be used for protective custody, administrative segregation, disciplinary segregation or other special custody status detention, absent emergency circumstances, but may be used for temporary detention of intoxicated individuals pursuant to New Mexico Statutes Annotated (NMSA), NMSA 1978 §§ 43-22 through 43-2-22. 88. Hygiene The County shall provide inmates detained in the booking area with appropriate shower opportunities and shall document when the inmates are offered the opportunity to shower.
Inmate Classification System 89. Classification System The County shall develop and implement an appropriate
classification system to protect inmates from unreasonable risk of harm. Inmates shall be timely classified and placed in housing appropriate for security and safety. The County shall use best efforts to anticipate periods of unusual intake volume and schedule sufficient classification staff to timely classify inmates.
Information Regarding Constitutionally Required Services −32−


90. Access to Information Regarding Constitutionally Required Services The County shall ensure that newly admitted inmates receive information they need to comply with facility rules and regulations, be protected from harm, report misconduct, access medical and mental health care and seek redress of grievances.
D. QUALITY MANAGEMENT 91. Quality Assurance System The County shall develop and implement quality assurance
policies, procedures and practices to evaluate and make necessary changes to medical and mental health care, suicide prevention, security and safety at the facility.
E. STAFF TRAINING AND SUPERVISION 92. Training Regarding this Agreement The County shall provide training and supervision to
staff sufficient to implement the provisions of this Agreement.
V. REPORTING REQUIREMENTS AND RIGHT OF ACCESS 93. The County shall submit quarterly compliance reports to the United States no later than
January 15, April 15, July 15 and October 15 during the term of this Agreement.
94. Each compliance report shall describe the actions the County has taken since the date the last report was due to implement this Agreement, and shall make specific reference to the Agreement provisions being implemented.
−33−


95. The County shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the SFCADC at all reasonable times for inspection and copying by the United States. In addition, the County shall maintain and submit upon request records or other documents to verify that they have taken such actions as described in their compliance reports (e.g., census summaries, policies, procedures, protocols, training materials, and incident reports) and will also provide all documents reasonably requested by the United States.
96. The United States and its attorneys, consultants, and agents shall have unrestricted access to the Detention Center, Detention Center inmates, Detention Center staff (including staff at SFCADC employed by any other outside medical services provider), and documents as reasonably necessary to address issues affected by this Agreement.
97. Within thirty (30) days of receipt of written questions from the United States concerning the County’s compliance with the requirements of this Agreement, the County shall provide the United States with written answers and any requested documents.
98. The County shall appoint a settlement Compliance Officer to oversee compliance with this Agreement and to serve as a point of contact.
VI. MONITORING AND ENFORCEMENT
−34−


99. Compliance Monitoring DOJ representatives, including its experts, may conduct at least four on-site compliance monitoring tours, subject to fiscal feasibility. The dates and duration of each on-site compliance monitoring visit shall be determined by DOJ representatives in consultation with the County. The County shall provide DOJ representatives with reasonable access to inmates and staff, documents, and information relating to implementation of this Agreement. DOJ shall have the right to conduct confidential interviews with inmates, and to conduct interviews with facility staff outside the presence of other staff or supervisors, and the County's experts shall be permitted to participate in these interviews. To the extent that the County proceeds in good faith to implement the terms outlined in this Agreement, DOJ shall conduct exit interviews on the final day of each monitoring tour and shall provide the County with written reports completed by DOJ experts regarding the Detention Center. The DOJ shall identify any deficiencies promptly following the monitoring tours. If, after indentifying deficiencies identified during the monitoring tours, the United States maintains that the County has failed to carry out any requirement of this Agreement, the United States shall notify the County of any instance(s) in which it maintains that the County has failed to carry out the requirements of this Agreement. The County may submit relevant additional information to the DOJ, including, but not limited to, reports of its own experts concerning the identified deficiencies. The submissions of the County will be considered by the DOJ.
100. Scope of Compliance Neither the United States nor its experts shall add provisions or expand the scope of this Agreement in any manner. −35−


101. Non-compliance The County shall take substantial steps to correct a claim by DOJ pursuant to provision 99 within a reasonable time but in no event more than 90 days from receipt of a notice of non-compliance. During the 90 days following receipt of a notice of deficiency, the United States and the County shall coordinate and discuss any areas of disagreement and attempt to resolve outstanding differences. If the United States and the County fail to reach an agreement, the DOJ may file a motion to enforce that provision of the Settlement Agreement that was the subject of the notice of deficiency by appropriate motion to the Court. The United States shall give the County fourteen (14) calendar days’ written notice of its intent to file a motion before filing the motion, during which time, the County shall have the opportunity to cure the deficiency. The time periods set out in this provision shall not apply to any claim by DOJ pursuant to provision 99 that conditions or practices at the SFCADC pose an immediate and serious threat to the life, health, or safety of SFCADC inmate(s), in which the situation shall be corrected immediately.
102. Inmate Deaths The County shall notify the United States immediately upon the death of any SFCADC inmate (either in the Detention Center or following transfer from the Detention Center to a hospital) and shall forward to the United States copies of any completed incident reports related to death, autopsies and/or death summaries of residents, as well as all final reports of investigations that involve inmates’ deaths.
−36−


103. Confidentiality Any information or documents obtained pursuant to this Agreement shall not be disseminated, except as provided by law, to any person not a party (or an employee or contractor of a party) to this Agreement. In the event of a request under the Freedom of Information Act (“FOIA”), or any other statute or provision of law, by a third party for disclosure of any information or documents provided by the County to the United States, the United States will assert all applicable exemptions from disclosure permitted by law. Additionally, the United States will notify the County of any such request if the United States intends to disclose any documents.
VII. IMPLEMENTATION AND TERMINATION 104. The County shall begin implementing all the terms of this Settlement Agreement
immediately upon the filing of this Agreement with the Court.
105. Except where otherwise specifically provided, the County shall complete implementation of all provisions of this Agreement within 180 days of the entry of this Agreement.
106. The effective date of this Agreement shall be November 1, 2007, and the Agreement shall terminate two years from its effective date.
107. The Agreement may terminate earlier than the two year period if the County has substantially complied with each of the provisions of the Agreement and has maintained substantial compliance for at least one year. Noncompliance with mere technicalities, or −37−


temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance.
108. The Agreement may terminate earlier as to a particular provision of the Agreement if the County has substantially complied with the provision in question and has maintained substantial compliance for at least one year. However, the Agreement shall terminate as to the following, specific provisions if the parties confirm that SFCADC has maintained substantial compliance as to the specific provision during the first two successive compliance monitoring visits following execution of this Agreement: provisions 14, 42, 51, 68, 69, 72, 77, and 84.
109. After substantial compliance with all provisions of this Agreement for a period of one year, or after substantial compliance with a particular provision of this Agreement for a period of one year, the DOJ and the County will execute a Termination of Agreement or a Partial Termination of Agreement that confirms the commitments contained in this Agreement have been satisfied and which relieves the parties from further monitoring and reporting. The termination document shall contain the following statement: “The DOJ agrees that termination of this Agreement is appropriate. There is no current pattern or practice of the County or its contractors violating the inmates’ constitutional rights addressed in our Agreement at the Santa Fe County Adult Detention Center.” −38−


110. If the County disagrees with findings of the DOJ as to its compliance with the terms of the Agreement, the County may file a motion to enforce the Agreement with the Court, but only after providing the DOJ, within 90 days, of notice of its intent to file such a motion, during which period the DOJ and the County shall coordinate and discuss the areas of disagreement and attempt to resolve the outstanding differences. If the United States and the County fail to reach an agreement, the County may file a motion to enforce the term of the Agreement that was the subject of the notice of deficiency, by appropriate motion to the Court.
111. The County may at its option submit to the United States a written certification of substantial compliance with any substantive provision(s) of this agreement by facsimile or overnight delivery. The certification shall provide evidence of compliance. If representatives of the United States do not provide written objection to such certification within forty-five (45) calendar days of receipt, the County will be deemed in substantial compliance with the specified provision(s) beginning on the date of delivery of the certification.
112. Failure by either party to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.
−39−


113. If any unforeseen circumstance occurs that causes a failure to timely carry-out any requirements of this Agreement, the County shall notify the United States in writing within 20 calendar days after the County becomes aware of the unforeseen circumstance and its impact on the County’s ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
114. In the event that any provision of this Agreement is declared invalid for any reason by the Court, said finding shall not affect the remaining provisions of this Agreement.
VIII. STIPULATION PURSUANT TO THE PRISON LITIGATION REFORM ACT, 18 U.S.C. § 3626
115. For the purposes of this Agreement only and in order to settle this matter, the Parties stipulate that this Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a). The Parties further stipulate and agree that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights alleged by the United States, is the least intrusive means necessary to correct these alleged violations, and will not have an adverse impact on public safety or the operation of a criminal justice system. Accordingly, the Parties agree and represent that the Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a).
−40−


116. The issue of liability has not been litigated. The County denies all allegations of the United States that violations of federal rights exist.
117. This Agreement is not intended to have any preclusive effect except between the Parties. Should the issue of the preclusive effect of this Agreement be raised, the Parties agree to certify that this Agreement was intended to have no such preclusive effect.
−41−


FOR THE UNITED STATES:
/s/ Larry Gomez LARRY GOMEZ United States Attorney District of New Mexico
Date: 2/28/08

/s/ Grace Chung Becker GRACE CHUNG BECKER Acting Assistant Attorney General Civil Rights Division
/s/ Shanetta Y. Cutlar SHANETTA Y. CUTLAR Chief Special Litigation Section
/s/ Tammie M. Gregg TAMMIE M. GREGG Principal Deputy Chief
/s/ Kerry Krentler Dean KERRY KRENTLER DEAN SHERIDAN L. ENGLAND Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section 950 Pennsylvania Ave., NW Washington, D.C. 20530

−42−


FOR THE COUNTY: 

Chairman Santa Fe County Board of County Commissions
/s/ Roman Abeyta ROMAN ABEYTA Santa Fe County Manager
/s/ Stephen C. Ross STEPHEN C. ROSS Santa Fe County Attorney
/s/ Annabelle Romero ANNABELLE ROMERO Director Corrections Department Santa Fe County
/s/ David Trujillo DAVID TRUJILLO Jail Administrator Santa Fe County Adult Detention Center
−43−


APPENDIX A
 Medical staffing: Nursing 12 hours on-site registered nurse coverage daily. Mid-level practitioner Minimum of 40 hours per week on-site nurse practitioner or physician’s assistant. Scheduling of health services staff Hours of registered nurses, nurse practitioners and physicians' assistants shall be scheduled so that at least one of those professionals is at the facility 16 hours per day, five days per week, during the hours when there is the most inmate activity. 
 The remaining eight hours of each weekday and the remaining 12 hours per day on weekends 
 may be covered by Licenses Practical Nurses. 
 Medical Director
 Minimum of 16 hours on-site physician per week, or, in the alternative, medical director is 
 on-site at the facility at least portions of four days per week. Medical Director must fulfill all 
 responsibilities outlined in provision 38.
 Physician
 Minimum of 16 hours on-site physician per week, or, in the alternative, physician is on-site at 
 the facility at least portions of four days per week. Physician must fulfill all responsibilities 
 outlined in provision 40. 
 Physician emergency on-call
 24-hour daily on-call physician coverage. 

−44−


Mental Health Staffing: 
 Psychiatrist
 Minimum of 20 hours of on-site psychiatrist per week, or, in the alternative, on-site psychiatrist 
 at least portions of three days per week. Psychiatrist must fulfill all responsibilities outlined in 
 provision 39. 
 Psychiatrist emergency on-call
 24-hour daily on-call psychiatrist coverage. 
 Mental Health Professionals
 Minimum of regular coverage by one full-time and one half-time Mental Health Professional. 
 Daily mental health staff must be present from 8 a.m. to 5 p.m. Monday through Friday. 
 On-call Mental Health Coverage
 24 hours on weekends 

−45−


 
 Case: 1:08-cv-212 As of: 01/12/2018 10:03 AM MST 1 of 2
U.S. District Court District of New Mexico − Version 6.1 (Albuquerque) CIVIL DOCKET FOR CASE #: 1:08−cv−00212−MCA−RHS

CLOSED

United States of America v. Santa Fe County et al Assigned to: Chief Judge M. Christina Armijo Referred to: Magistrate Judge Robert Hayes Scott Cause: 42:1983 Civil Rights Act
Plaintiff

Date Filed: 02/28/2008 Date Terminated: 04/30/2008 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Gregory James Fouratt US Attorney's Office − ABQ District of New Mexico PO Box 607 Albuquerque, NM 87103 Email: greg.fouratt@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Kerry Krentler Dean U.S. Dept. of Justice 950 Pennsylvania Avenue, N.W. PHB 5026 Washington, DC 20530 202−514−1841 Fax: 202−514−0212 Email: kerry.k.dean@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Sheridan Leigh England United States Department of Justice Civil Rights Division Special Litigation Section 601 D Street NW Room 5026 Washington, DC 20530 202−616−2249 Fax: 202−514−0212 Email: sheridan.england@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Jan Elizabeth Mitchell United States Attorneys Office P.O. Box 607 Albuquerque, NM 87102 505 346−7274 Fax: 505 346−7205 Email: jan.mitchell@usdoj.gov ATTORNEY TO BE NOTICED

V. Defendant Santa Fe County
Defendant

Case: 1:08-cv-212 As of: 01/12/2018 10:03 AM MST 2 of 2
Santa Fe County Adult Detention Center
Defendant Anabelle Romero Corrections Director
Defendant David Trujillo Jail Administrator
Defendant Santa Fe County Board of County Commissioners

Date Filed 02/28/2008
02/28/2008 02/28/2008 03/03/2008 03/04/2008
03/06/2008
04/30/2008 04/30/2008
07/02/2008 10/30/2009

# Docket Text
1 COMPLAINT against all defendants ( Filing Fee − Waived), filed by United States of America. (Attachments: # 1 Exhibit Certificate of the Attorney General# 2 Civil Cover Sheet)(Mitchell, Jan) (Entered: 02/28/2008)
Judge Alan C. Torgerson and Robert Hayes Scott assigned. (nm) (Entered: 02/28/2008)
2 Letter re: Consent to Proceed before a US Magistrate Judge (nm) (Entered: 02/28/2008)
3 NOTICE of Refusal to Proceed Before US Magistrate Judge by United States of America (Mitchell, Jan) (Entered: 03/03/2008)
4 MINUTE ORDER re: 3 Plaintiff's Notice of Consent/Refusal to Proceed Before US Magistrate Judge, Judge M. Christina Armijo added. Judge Alan C. Torgerson no longer assigned to case. (jrm) (Entered: 03/04/2008)
5 Joint MOTION for Order for Entry of Settlement Agreement by United States of America. (Attachments: # 1 Exhibit Settlement Agreement)(Mitchell, Jan) (Entered: 03/06/2008)
6 ORDER by District Judge M. Christina Armijo granting 5 Joint Motion for Entry of Settlement Agreement (al) (Entered: 04/30/2008)
7 ORDER CLOSING CASE for statistical purposes and requiring parties to submit quarterly joint status reports by District Judge M. Christina Armijo (al) (Entered: 04/30/2008)
8 STATUS REPORT − JOINT by United States of America (Dean, Kerry) (Entered: 07/02/2008)
11 ORDER OF FINAL DISMISSAL by District Judge M. Christina Armijo. (dc) (Entered: 10/30/2009)

 
 Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 1 of 6

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

UNITED STATES OF AMERICA

)

)

Plaintiff,

)

)

v.

)

)

SANTA FE COUNTY I

)

SANTA FE COUNTY ADULT

)

DETENTION CENTER,

)

ANNABELLE ROMERO, Corrections )

Director,

)

DAVID TRUJILLO, Jail

)

Administrator,

)

SANTA FE BOARD OF COUNTY

)

COMMISSIONERS

)

)

__________D__e_fe_n_d__a_n_ts_._________

)
)

CIVIL NO.

COMPLAINT THE UNITED STATES OF AMERICA alleges:
1. The Attorney General files this complaint on behalf of the United States of America pursuant to the Civil Rights of Institutionalized Persons Act of 1980, 42 U.S.C. § l997, to enjoin the named Defendants from depriving persons incarcerated at the Santa Fe County Adult Detention Center ("SFCADC"), located in Santa Fe, New Mexico, of rights, privileges, or immunities secured and protected by the Constitution of the United States.
JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under
28 u.s.c. § 1345.·

Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 2 of 6
3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 1997a.
4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C. § 1997b have been met. The Certificate of the Attorney General is appended to this Complaint and is incorporated herein.
5. Venue in the District of New Mexico is proper pursuant to 28 U.S.C. § 1391.
DEFENDANTS 6. Defendant SANTA FE COUNTY is a governmental subdivision created under the laws of the State of New Mexico. The SFCADC is a division of the Santa Fe County government. The County owns and operates SFCADC, located in Santa Fe County. 7. Defendant SANTA FE COUNTY is the entity charged by the laws of the State of New Mexico with authority to maintain SFCADC and is responsible for the conditions of confinement and health and safety of persons incarcerated at SFCADC. 8. · Defendant ANNABELLE ROMERO is the Corrections Director of SFCADC, and is sued in her official capacity.
-2-

Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 3 of 6
9. Defendant David Trujillo is the Santa Fe County Jail Administrator, and is responsible for the day-to-day operations of SFCADC. In his official capacity as Jail Administrator, he has the custody, control, and charge of the jail and inmates. Jail Administrator Trujillo is sued in his official capacity.
10. Defendants, SANTA FE BOARD OF COUNTY COMMISSIONERS, are the County's governing authority, the Board of Commissioners has funding, claims resolution, and oversight powers over SFCADC. The Defendant COMMISSIONERS are sued in their official capacities.
11. Defendants are legally responsible, in whole or in part, for the operation and conditions of SFCADC, and for the health and safety of persons incarcerated in SFCADC.
12. At all relevant times, the Defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law.
FACTUAL ALLEGATIONS 13. SFCADC is an institution within the meaning of 42
u.s.c. § 1997 (1).
14. Persons confined to SFCADC include both pre-trial detainees and sentenced inmates.
-3-

Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 4 of 6
15. Defendants have engaged in and continue to engage in a pattern or practice of failing to protect inmates at SFCADC from serious harm and undue risk of serious harm by, inter alia, failing to provide adequate medical and mental health care, and failing to provide safe and sanitary living conditions.
16. The factual allegations set forth in paragraph 15 have.been obvious and known to Defendants for a substantial period of time; yet Defendants have failed to address adequately the conditions described.
VIOLATIONS ALLEGED 17. Through the acts and omissions alleged in paragraphs 15 and 16, Defendants have exhibited deliberate indifference to the health and safety of SFCADC inmates, in violation of the rights, privileges, or immunities of those inmates as secured or protected by the Constitution of the United States. U.S. Const. amend. VIII, XIV. 18. Unless restrained by this Court, Defendants may continue to engage in the acts and omissions set forth in paragraphs 15 and 16 that deprive persons confined at SFCADC of rights, privileges, or immunities secured or protected by the Constitution of the United States.
-4-

Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 5 of 6
PRAYER FOR RELIEF 19. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and declaratory relief. WHEREFORE, the United States prays that this Honorable Court enter an order permanently enjoining Defendants, their officers, agents, employees, subordinates, successors in office, and all those acting in concert or participation with them from continuing the acts, omissions, and practi~es set forth in paragraphs 15 and 16 above, and that this Court require Defendants to take such actions as will ensure lawful conditions of confinement are afforded to inmates at the Santa Fe County Jail. The United States further prays that this Court grant such other and further equitable relief as it may deem just and proper.
Respectfully submitted,
ukasey Attorney General of the United States·
-5-

Case 1:08-cv-00212-MCA-RHS Document 1 Filed 02/28/08 Page 6 of 6

~GREGORY:~ ·J~..·. FOURATT United States Attorney District of New Mexico 201 :3rd St NW Albuquerque/ New Mexico

87102

·~,~~
JGreehUng Be ker · ·
Acting Assistant Attorney General . Civil R' hts Division

FILED ELECTRONICALLY 2/28/08

crAN ELIZABETH MITCHELL
Assistant u.s. Att6rney

P.O. Box 607

Albuquerque/ NM 87103

l .

I 505.346.7274

r

jan.mitchell®usdoj.gov

·Litigation Section

Principal Deputy Chief Special Litigation Section·
~---
KERRY-KRENTLER DEAN .. SHERIDAN L. · ENGLAND
Attorneys · Civil Rights Division Special Litigation-Section ·U.S. Department of Justice 601 D Street 1 NW Room·5026· Washington/ DC 20530 (202) 514-1841

,·

i

J

I

- 6 -·

 
 Case 1:08-cv-00212-MCA-RHS Document 8 Filed 07/02/08 Page 1 of 4

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

UNITED STATES OF AMERICA

)

)

Plaintiff,

)

)

v.

)

)

SANTA FE COUNTY,

)

SANTA FE COUNTY ADULT

)

DETENTION CENTER,

)

ANNABELLE ROMERO, Corrections )

Director,

)

DAVID TRUJILLO, Jail

)

Administrator,

)

SANTA FE BOARD OF COUNTY

)

COMMISSIONERS

)

)

___________D__e_fe_n__d_a_n_t_s.__________

)
)

CIV 08-212 MCA/RHS

JOINT STATUS REPORT
The United States, Plaintiff, and Santa Fe County (County), et al., Defendants, respectfully submit this Joint
~.
Status Report, as ~equired by the Court's Order of April 30, 2008, regarding the County's progress in implementing the Settlement Agreement entered by the Court on April 30, 2008
in this matter:

1. On February 19-21, 2008, the United States, with its expert consultants, conducted its initial compliance visit of the Santa Fe County Adult Detention Center (SFCADC) under the Settlement Agreement. The County provided extensive documents in response to the United States' requests before, during, and following the visit.

Case 1:08-cv-00212-MCA-RHS Document 8 Filed 07/02/08 Page 2 of 4
2. Due to a misunderstanding, the County did not provide the first compliance report, due January 15, 2008, pursuant to provision 93 of the Settlement Agreement. The County has not provided the second compliance report, due April 15, 2008. The next compliance report is due July 15, 2008.
3. The United States provided the County with a written assessment of the County's compliance with the medical and mental health care provisions of the Settlement Agreement, as assessed through the February 2008 tour and document review, on May 14, 2008~ along with the United States' expert consultants' reports on medical and mental health care at SFCADC.
4. The United States provided the County with a written assessment of the County's compliance with the security and safety provisions of the .Settlement Agreement, as asses.sed through the February 2008 tour and document review, on June 20, 2008, along with the United States' expert consultant's report on security and safety at SFCADC.
- 2-

Case 1:08-cv-00212-MCA-RHS Document 8 Filed 07/02/08 Page 3 of 4

5. On June 24-25, 2008, the United States, with its expert consultants, conducted its second compliance on-si·te review of SFCADC under the Settlement Agreement.

6. While the County has not yet reached compliance with all the provisions of the Settlement Agreement, the County has achieved progress in many areas.

7. The parties are working together, cooperatively and in good faith, toward a goal of substantial compliance with each provision of the Settlement Agreement.

FOR THE UNITED STATES:

Respectfully submitted,

GREGORY J. FOURATT United States Attorney

SHANfiTTA Y. CUTLAR
chief Special Litigation Section Civil Rights Division

- 3-

Case 1:08-cv-00212-MCA-RHS Document 8 Filed 07/02/08 Page 4 of 4

JAN ELIZABETH MITCHELL·
A~sistant u.s. Attorney

P.O. Box 607

Albuquerque, NM 87103

505.346.7274

0

Jan.mitcheil®usdoj.gov

Principal Deputy Chief Special Litigation Section

KERRY KRENTLER DEAN .. ·sHERIDAN "t; ·:· l!fNGLAND

Trial Attorneys ·

Civil Rights Division Special Litigation-Section

·U.S. Department of Justice

601 D Street,· NW

W~shington, DC 20530

202.514.1841

0

kerry.k.dean®usdoj.gov

Santa Fe County Att~rney 102 Grant Ave. Santa Fe, NM 87504-0276·
505.986.6279
·sross@co.santa-fe.nm.us

- 4~

 
 Case 1:08-cv-00212-MCA-RHS Document 11 Filed 10/30/09 Page 1 of 1

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

UNITED STATES OF AMERICA,
Plaintiff,
vs.
SANTA FE COUNTY; SANTA FE COUNTY ADULT DETENTION CENTER; ANNABELLE ROMERO, Corrections Director; DAVID TRUJILLO, Jail Administrator; SANTA FE BOARD OF COUNTY COMMISSIONERS,
Defendants.

No. CIV 08-00212 MCA/RHS

ORDER OF FINAL DISMISSAL WHEREAS a Settlement Agreement was approved by this Court on April 30, 2008 and whereas the parties have filed a Joint Status Report recommending the expiration of the Settlement Agreement, which the Court accepts as a request for formal dismissal of this matter; IT IS HEREBY ORDERED that 1. The Settlement Agreement and its associated Orders are terminated. 2. This case is DISMISSED with prejudice. SO ORDERED, this 30th day of October, 2009, in Albuquerque, New Mexico.

M. CHRISTINA ARMIJO United States District Judge

 
 Case 1:08-cv-00212-MCA-RHS Document 5 Filed 03/06/08 Page 1 of 3

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

UNITED STATES OF AMERICA

)

)

Plaintiff,

)

)

v.

)

)

SANTA FE COUNTY,

)

SANTA FE COUNTY ADULT

)

DETENTION CENTER,

)

ANNABELLE ROMERO, Corrections )

Director,

)

DAVID TRUJILLO, Jail

)

Administrator,

)

SANTA FE BOARD OF COUNTY

)

COMMISSIONERS

)

)

Defendants.

)

----------------------~-----)

CIV 08-212 MCA/RHS

JOINT MOTION FOR ENTRY OF SETTLEMENT AGREEMENT

The United States, Plaintiff, and Santa Fe County, et

al., Defendants, having entered into the attached Settlement

Agreement, jointly move this Court for entry of an Order

conditionally dismissing this action, pursuant to Fed. R.

Civ. P. 4l(a) (2), conditioned upon Defendants' achieving

substantial compliance with the terms of the Settlement

Agreement. The parties respectfully request that the Court

place the case on its inactive docket while retaining

jurisdiction over the case until a final dismissal with

prejudice is entered.

Case 1:08-cv-00212-MCA-RHS Document 5 Filed 03/06/08 Page 2 of 3

FOR THE UNITED STATES:
GREGORY J. FOURATT United States Attorney
~~\L~ Filed.Electronically 3/6/08 JAN ELIZABETH MITCHELL Assistant U.S. Attorney P.O. Box 607 Albuquerque, NM 87103 505.346. 7274" Jan.mitche~l@usdoj.gov

Respectfully submitted,

.· h~Cy:fi~L.¥Y

SHANETTA y. CUTLAR

. ·)"I ¥:?

Chief Special Litigation Section Civil Rights Division

Principal Deputy Chief Special Litigatio"n Section

KERRY KRENTLER DEAN SHERIDAN L. ENGLAND.
Attorneys Civil Rights Division Special Litigation Section U.S. Department of Justice 601 D Street, NW Washington, DC 20530. 202.514.1841 Kerry.k.dean®usdoj .gov

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Case 1:08-cv-00212-MCA-RHS Document 5 Filed 03/06/08 Page 3 of 3
FOR .THE COUNTY: STEPHEN C. ROSS Santa Fe County Attorney 102 Grant Ave. Santa Fe, NM 87504-0276
505.98~.6279
sross®co. santa-fe .:nm·. us
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 1 of 46

IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW MEXICO

UNITED STATES OF AMERICA

)

)

Plaintiff,

)

)

v.

)

)

SANTA FE COUNTY,

)

SANTAFECOUNTY ADULT

)

DETENTION CENTER,

)

ANNABELLE ROMERO, Corrections )

Director,

)

DAVID TRUJILLO, Jail

)

Administrator,

)

THE BOARD OF COuNTY

)

COMMISSIONERS OF

)

SANTA FE COUNTY,

. )

)

Defendants.

)

)

CIV 08-212 MCAIRHS

SETTLEMENT AGREEMENT

I. INTRODUCTION 1. On March 20, 2002, the United States, through the Department of Justice ("DOJ"),
notified Santa Fe County officials of its intention to investigate conditions of confinement at the Santa Fe County Adult Detention Center ("SFCADC" or "the Detention Center"), pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997.

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EXHIBIT A

Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 2 of 46
2.. On May 7-10 and 29-31 2002, the United States conducted investigatory tours of SFCADC with consultants in the fields of correctional health care, correctional mental health care, Detention Center security and safety, and employee training and supervision.
3. On March 6, 2003, the United States issued a findings letter pursuant to 42 U.S.C. § 1997 that concluded that certain conditions at SFCADC violate the constitutional or statutory rights of individuals confined at the Detention Center. The Col:mty denied, and continues to deny, that conditions at SFCADC violate the constitutional or statutory rights of individuals confined at SFCADC.
4. On November, 1, 2004, Santa Fe County and its elected officials, employees, agents, and contractors responsible for the operation of SFCADC and the United States entered into a Memorandum of Agreement ("MOA") to resolve the United States' CRIPA investigation and ensure constitutional conditions of confinement at SFCADC. The MOA terminated by its own terms on October 31, 2007.
. 5. Following execution of the MOA, the United States and its expert consultants conducted compliance tours in March 2005, July 2005, February 2006, August 2006, and March 2007. The United States issued detailed, written compliance assessments to the County on July 14, 2005, July 24, 2006, January 12, 2007, and July 6, 2007.
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6. As the County is not yet in substantial compliance with all provisions of the MOA, the parties have agreed to enter into this Agreement.
II. GENERAL PROVISIONS 7. This Settlement Agreement (the "Agreement") is entered into between the United States
and SANTA FE COUNTY, SANTA FE COUNTY ADULT DETENTION CENTER, ANNABELLE ROMERO, Corrections Director, DAVID TRUJILLO, Jail Administrator, and THE BOARD OF COUNTY COMMISSIONERS OF SANTA FE COUNTY; and their successors, contractors, and agents (collectively, the "County").
8. The Agreement resolves the investigation conducted by the United States at SFCADC pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. The Agreement addresses the corrective measures set forth by the United States in its March 6, 2003 findings letter to the County and subsequent assessments of the County's compliance with the MOA on July 14, 2005, July 24, 2006, January 12, 2007, and July 6, 2007. This Agreement replaces the MOA. This Agreement does not serve as an adniission by the County that corrective measures are necessary to meet the constitutional and statutory rights of inmates at SFCADC.
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9. In conformity with CRIPA, this Agreement represents a voluntary effort by the County to meet the concerns raised by the United States' investigation. See 42 U.S.C. § 1997b (a)(2)(B) and§ 1997g.
10. Pursuant to 42 U.S.C. § 1997b(a)(2)(B) and§ 1997g, the United States agrees to support the County's application for federal funding conditioned upon the County's proper implementation of the suggested remedial measures.
an 11. Nothing in this Agreement shall be construed as an acknowledgment, admission, or
evidence of liability ofthe County under CRIPA, the Constitution or federal or state law, and this Agreement may not be used as evidence of liability in this or any other civil or criminal proceeding.
12. The signatures below of officials representing the United States and the County signify that these parties have given their final approval to this Agreement.
13. This Agreement is enforceable only by the parties or, upon motionby a party to enforce terms of this Agreement, by the Court. This Agreement is binding upon the parties, by and through their officials, agents, employees, and successors. No person or entity is intended to be a third party beneficiary of the provisions of this Agreement for purposes of any civil, criminal, or administrative action, and, accordingly, no person or entity may
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 5 of 46
assert any claim or right as a beneficiary or protected class under this Agreement in any civil, criminal, or administrative action. Similarly, this Agreement does not authorize, nor shall it be construed to authorize, access to County documents by persons or entities not a party to this Agreement. This Agreement is not intended to impair or expand the right of any person or organization to seek relief against the County or its officials, employees, or agents for their conduct. This Agreement does not alter legal standards governing any such claims, including those standards established by New Mexico law.
14. This Agreement shall constitute the entire integrated Agreement of the parties. With the exception of the March 6, 2003 findings letter, no prior contemporaneous communications, oral or written, or prior drafts shall be relevant or admissible for purposes of determining the meaning of any provisions herein in any litigation or any other proceeding. Both parties acknowledge that the findings set forth in the March 6, 2003 letter will not be admitted for purposes of establishing conditions at the Santa Fe County Adult Detention Facility, but the defendant agrees to its admission to establish that the United States notified the defendant of its experts' opinions about the specific conditions of the facility identified in that letter. Any amendment to this Agreement shall be in writing and signed by both parties.
15. Since the United States issued its last compliance assessment on July 6, 2007, the County has made progress in remedying the problems the United States identified in the March 6,
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2003 findings letter and subsequent compliance assessments. The parties agree that it is in their mutual interests to avoid litigation. The parties further agree that resolution of this matter pursuant to this Agreement is in the best interests of SFCADC inmates. Now, therefore, pursuant to Fed. R. Civ. P. 41(a)(2), the parties hereby agree to file this Agreement in the United States District Court for the District ofNew Mexico, together with a Complaint and a motion to conditionally dismiss the Complaint under the conditions set forth in this Agreement. The parties further agree that this case will remain on the Court's inactive docket during the term of, and subject to, this Agreement, and that, from time to time, the Court may hold, at the request of either party, status conferences for the sole purpose to assist the parties to informally resolve disputes, if any, vuntil this Agreement terminates.
16. All parties shall bear their own costs, including attorneys' fees, in this and any subsequent proceeding.
17. This Agreement shall take effect on November 1, 2007.
18. The County shall ensure that all Santa Fe County Departments take any actions necessary to comply with the provisions of this Agreement.
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19. The Court has jurisdiction over this action pursuant to 28 U.S.C. § 1331, 28 U.S.C. § 1345, and 42 U.S.C. § 1997. Venue is proper in this district pursuant to
28 u.s.c. § 1391(b).
III. DEFINITIONS 20. "SFCADC" or "the Detention Center" shall refer to the Santa Fe County Adult Detention
Center, sometimes called the Santa Fe County Correctional Facility, which is currently located at 4312 New Mexico Highway 14, Santa Fe, NewMexico, as well as any facility that is built, leased, or otherwise used, to replace or supplement the Detention Center. "SFCADC" does not include alternatives to incarceration such as off-site drug and alcohol treatment centers, detoxification centers, outside mental health treatment facilities, electronic monitoring programs, facilities for the incarceration of minors, or work release centers.
· 21. "DOJ" shall refer to the United States Department of Justice, which represents the United States in this matter.
22. "The County" means Santa Fe County and its elected officials, employees, agents, and contractors responsible for the operation of and provision of services at the Detention Center.
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 8 of 46
23. "Court" or "the Court" means the United States District Court for the District ofNew Mexico.
24. "Include" or "including" shall mean "include, but not be limited to" or "including, but not limited to."
25. "Inmate" or "inmates" shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at either the existing Detention Center or any institution that is built or used to replace the Detention Center or any part of the Detention Center.
26. Consistent with, or in accordance with, the term "generally accepted professional standards of care" shall mean a decision by a qualified professional that is substantially aligned with contemporary, accepted professional judgment, practice, or standards as to demonstrate that the person responsible based the decision on such accepted professional judgment.
27. "Quality Assurance" means a system of self-audit and improvement to assess the implementation and effectiveness of all remedies instituted pursuant to this Agreement, to identify deficits that may exist, and to effectuate new measures to cure deficits identified.
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28. "Effective date" shall mean November 1, 2007.
29. "Health services staff'' means any and all healthcare staff, who by virtue of license, credentials and/or training, provide health services at the Detention Center.
30. "Inmates with chronic disease" shall include, but are not limited to, those inmates who have been diagnosed with diabetes, hypertension, asthma, cardiac disease, Human Immunodeficiency Virus ("HIV") infection, viral hepatitis, and seizure disorder, and may include inmates with other chronic diseases.
31. "Medical staff'' means licensed physicians, licensed physician's assistants, and licensed nurse practitioners employed at the Detention Center currently licensed to the extent required by the State ofNew Mexico to deliver those health services she or he has undertaken to provide.
32. "Mental health professional" means an individual employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those mental health services she or he has undertaken to provide.
33. "Nursing staff'' means licensed registered nurses ("RNs") and licensed practical nurses ("LPNs") employed at the Detention Center employed at the Detention Center currently
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 10 of 46
licensed to the extent required by the State ofNew Mexico to deliver those health services they have undertaken to provide. It does not include nurse's aides, certified nursing assistants, or EMTs.
34. "The parties" means the County and the United States.
35. "Train," when the term is used in remedial provisions of this Agreement, means adequately instruct in the skills addressed, including assessment of mastery of instructional material.
36. Throughout this Agreement, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance. "Substantial compliance" indicates that the Detention Center has achieved compliance with most or all components of the relevant provision of the Agreement. "Partial compliance" indicates that compliance has been achieved on some of the components of the relevant provision ofthe Agreement, but significant work remains. "Non-compliance" indicates that most or all of the components of the Agreement provision have not yet been met.
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IV. SUBSTANTIVE PROVISIONS A. MEDICAL AND MENTAL HEALTH CARE Standard 37. Serious Medical and Mental Health Needs. The County shall provide adequate services
to address the serious medical and mental health needs of all inmates.
Medical and Mental Health Staffing and Professional Credentials 38. Medical Director The medical director of the Detention Center shall be a qualified,
licensed physician, shall supervise all clinical practices and medical policy development at the facility, and shall communicate problems and resource needs to the Jail Administrator. The medical director of the Detention Center shall have ultimate responsibility for supervising clinical decision-making.
39. Psychiatrist Staffing The County shall retain a psychiatrist for a sufficient number of hours per week to see patients, prescribe psychotropic medications, develop individualized treatment plans for inmates with serious mental health needs, supervise care provided by other mental health practitioners at the facility, review charts, review the results of diagnostic and laboratory tests, and review policies, procedures, and protocols. The psychiatrist shall take a lead role in mental health services management as well as clinical treatment, shall communicate problems and resource needs to the Jail
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Administrator, and shall serve as the ultimate clinical authority at the facility for mental · health care.
40. Physician Staffing Physician staffing shall be sufficient to provide adequate care for patients, review policies, procedures and protocols, supervise care provided by lower level prCJ.ctitioners including chart review, and participate in quality improvement and infection control programs.
41. Health Services Staffing Health services staffing levels shall be sufficient to provide adequate treatment for inmates' serious medical and mental health needs by qualified and trained health services and mental health professionals. Appendix A sets forth the required staffing minima for registered nurses, psychiatrist, physician, and other medical and mental health staff.
42. Scope of Practice All persons providing medical or mental health care shall meet applicable state licensure and/or certification requirements. Health services staff shall not practice outside the scope of their licensure and training. Upon hiring and annually, SFCADC shall verify that all health services staff has current, valid, and unrestricted professional licenses.
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43. Health Services Staff Training The County shall train medical and mental health staff sufficiently to perform their duties at the Detention Center in accordance with this Agreement. This training shall include guidance to ensure that staff does not practice outside the scope of their licensure, and that they refer inmates with serious medical and mental health needs for care by those qualified to treat such needs.
44. Correctional Officer Identification of and Response to Urgent Medical and Mental Health Needs The County shall implement policies and procedures for correctional officers to refer imitates who exhibit signs and symptoms of urgent medical or mental health needs including intoxication and withdrawal for appropriate medical or mental health attention. The County shall make best efforts to train all correctional officers who work with inmates to provide first aid-responder assistance in an emergency situation (CPR, valve resuscitation and -how to address serious bleeding). The County shall ensure that trained staff is available to respond in a timely fashion to any medical emergency at the facility. The County shall provide all personnel who have inmate contact with the necessary protective gear (including rubber gloves and protective mouth shields) to provide first line emergency response. The County shall train all correctional officers who work with inmates to understand and identify signs and symptoms of drug and alcohol withdrawal and recognize other medical and mental health lirgencies.
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Intake Medical and Mental Health Screening, Referral and Assessment 45. Privacy The County shall provide for an inmate's reasonable privacy in medical and
mental health care, and maintain confidentiality of inmates' medical and mental health status, subject to legitimate secmity concerns and emergency situations.
46. Intake Clinical Health Screening The County shall provide for intake clinical health screening by health services staff for new inmates and inmates transferring from other correctional institutions in a reasonably private setting at the time of booking. For this intake health screening, health services staff shall record and seek the inmates' cooperation to provide: (1) medical, surgical, and mental health history, including current ·or recent medications; (2) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use; (3) history of substance abuse and treatment; (4) pregnancy; (5) history and symptoms of communicable disease; (6) suicide risk history; and (7) history of mental health treatment, including medication and hospitalization. Inmates who screen positively for any of these items shall be referred to the medical unit for immediate treatment or for referral at a reasonable time, as appropriate. Staff shall attempt to elicit the amount, frequency and time of the last dosage· of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. The County shall ensure that staff performing initial health screenings is trained to complete the assessments. This initial health screening information shall promptly become part of an inmate's medical record.
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47. Observation of Inmates Upon Intake Correctional officers supervising newly arrived inmates shall physically observe the conduct and appearance of these inmates to determine whether they have a more immediate need for medical or mental health attention prior to or following their intake health screenings by health services staff.
48. Unified Medical Record Staff shall retrieve all retrievable medical and mental health records from an inmate's previous period of incarceration at the Detention Center (where the record can be positively matched to the inmate) prior to the inmate's next medical or mental health encounter after the clinical health screening, and shall consolidate them with the inmate's current medical record. The County shall maintain unified medical, dental and mental health records. All records shall be timely filed in patients' medical charts. For purposes ofthis Agreement, "timely filed" means within ten (10) days of receipt, review, creation, or use, except for medication administration records (see provision 71 ), which shall be filed within ten (1 0) days of the end of a month. Laboratory reports shall be timely reviewed by the appropriate health services staff, filed within three (3) days of receipt, and noteworthy results reported to inmates as medically appropriate. In the event the County moves to an electronic medical record, that system will conform to the concepts set forth in this provision recognizing that the process of electronic medical record keeping may differ slightly from the process set forth above.
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49. Outside Medical Records For inmates with chronic diseases, pregnancy or mental illnesses, if a member of the medical staff or a mental health professional requests retrieval of outside medical records, the County shall request a release of information from the inmate and if granted, shall send a request for the inmate's treatment records to current treatment providers identified by the inmate within two days.
50. Tuberculosis ("TB") Testing As part of the fourteen day health assessment, the County shall routinely screen all inmates for symptoms or risk factors for TB. Pursuant to Centers for Disease Control ("CDC'') Guidelines, if health services staff determine that an inmate is at risk for TB, SFCADC will perform a tuberculin skin test (i.e. Mantoux "PPD"), unless such test is unnecessary (i.e. history of prior positive tests) or medically contra-indicated. The County shall read the PPD forty-eight (48) to seventy-two (72) hours after placement of the PPD. Within 72 hours of determining that an inmate's PPD test is positive, the County shall schedule an appointment for a chest x-ray of the inmate. The County shall ensure that inmates are transported to the scheduled appointment. The County shall follow CDC guidelines in effect on the date this Agreement is executed, for management of inmates with TB infection, including providing prophylactic medication when medically appropriate, or shall follow screening and assessment guidelines set forth by the New Mexico Department of Health, as appropriate. The County will consider implementing subsequently revised CDC guidelines. Inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for
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contagious TB, and housed in the health services unit until they may be transferred to .another facility or location where respiratory isolation is available. The facility shall provide for infection control and for the safe housing and transportation of such inmates.
51. Screening, Testing and Treatment of Communicable Diseases The County shall implement a policy for STD screening, testing, and treatment that is consistent with the standards of the New Mexico Department of Health and appropriate to the inmate population of the Detention Center. The policy shall be implemented within 120 days of the date this Agreement is executed.
52. Continuity of Medication at Intake The County shall implement a medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a timely manner, as medically appropriate when medically necessary. Within twenty-four hours of an inmate's arrival at the facility, or sooner if medically necessary, the County shall decide whether to continue the same or comparable medication for serious medical needs as an inmate reports on arrival that she or he has been prescribed. If the inmate's reported medication is discontinued or changed by medical staff, medical staff shall evaluate the inmate face-to-face as soon as medically appropriate. The County shall implement a protocol and screening tool to guide health services staff in gathering necessary information and present such information to medical staff for medication continuity decisions.
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53. Expedited Referral for Medical and Mental Health Needs When the initial clinical health screening indicates that an inmate has acute health or mental health needs, the County shall provide timely care by trained and licensed medical staff, registered nurses, or mental health professionals as soon as medically necessary, within the recommended timeframe as set out by the evaluating health professional (a nurse practitioner, physician's assistant, or physician). The County shall schedule individuals with chronic health or mental health needs and those who are pregnant but who present in a stable condition to be seen by medical staff or mental health professionals as soon as medically necessary. Incoming inmates who present with current risk of suicide or other acute mental health needs will be immediately referred for a mental health evaluation by a mental health professional. Staff will observe such inmates until they are seen by mental health professionals. Incoming inmates reporting these conditions will be housed under . , appropriate conditions in the Health Services Unit unless and until a mental health care professional clears them for housing in segregation or with the general population.
54. Fourteen Day Health Assessment The County shall perform a screening physical and mental health assessment for each inmate within fourteen (14) days of an in.i:nate's arrival at the Detention Center, unless the County knows that an inmate will be incarcerated for fewer than thirty (30) days. For inmates incarcerated for fewer than 30 days, the County shall conduct the testing required by provision 50. The assessment shall include a comprehensive medical history, physical examination, mental health history, and current
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mental health status examination. Qualified health services staff may gather health history and vital signs from an inmate. The physical examination shall be conducted by medical staff or registered nurses. Records documenting the assessment and results shall become part of each inmate's medical record. A re-admitted inmate or an inmate transferred from another facility who has received a documented full health assessment within the previous three months and whose receiving screening shows no change in the inmate's health status need not receive a new full physical health assessment. For such inmates, qualified personnel shall review prior records and update tests and examinations as needed.
55. Comprehensive Mental Health Evaluation The County shall ensure that any inmate who screens positively for mental illness, suicidal ideation, or other mental health needs during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services receives a comprehensive mental health evaluation from a mental health professional licensed and trained to diagnose, within twenty four (24) hours of referral for an expedited comprehensive evaluation, or seventytwo (72) hours of referral for a routine comprehensive evaluation. The comprehensive mental health evaluation shall include a recorded diagnosis section, including a standard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If mental health staff finds a serious mental
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illness, they shall treat appropriately. The County shall review available information regarding any diagnoses made by the inmate's community or hospital treatment provider.
Access to Medical and Mental Health Services 56. Access to Medical and Mental Health Services Initial paper screening of medical and
· mental health care request slips (or electronic records if an electronic medical record is implemented at the facility) shall be conducted within twenty-four (24) hours of health services staffs receipt and may be conducted by an LPN or EMT. All inmates who submit medical care request slips indicating the need for clinical judgment and/or physical assessment shall be seen by medical staff or registered nurses as soon as medically necessary. Registered nurses performing acute care shall be guided by physician approved nursing protocols that are updated annually, and shall consult with or refer patients to the on-call medical staff as appropriate. Medical care requests that do not indicate the need for clinical judgment and/or physical assessment may be handled by LPNs. The County shall implement a protocol guiding the distinction between those medical care request slips that require face-to-face services and those that do not. Written requests for mental health services shall be forwarded to a mental health professional and timely evaluated by him or her. Notwithstanding the foregoing, the health services worker forwarding sick call slips to mental health providers shall respond to any apparently emergent need in accordance with provisions 59 and 60.
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57. Acute care policies, procedures and practices The County shall ensure that its acute care policies, procedures, and practices address and guide the following: (1) written medical and mental health care request slips available in English and Spanish; (2) a confidential
· collection method in which the request slips are collected by health services staff seven days per week; (3) a logging procedure to record the date and summary of each request for acute care, the date the inmate was seen and the name of the person who saw him or her, the disposition of the medical or mental health visit (e.g., referral; whether inmate scheduled for acute care visit), and if follow up care is necessary, the date and time of the inmate's next appointment; (4) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; (5) opportunity for all inmates, irrespective of primary language, to access medical and mental health care; and (6) recording of results ofthe medical or mental health care request in the inmate's medical record.
58. Rounds Mental health professionals shall make monthly rounds in the housing units to identify inmates who may have mental health needs but who have not accessed mental health services through the sick call system.
59. ·Expedited Referral The County shall ensure that inmates requesting mental health services, inmates who become suicidal, inmates who are referred for mental health services by correctional officers, and inmates who develop serious mental illness while
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incarcerated, are evaluated and treated timely, irrespective of the manner in which the services are requested. Mental health professionals shall be provided with up-to-date housing lists of inmates to ensure continuity of care.
Emergency Care 60. Response to Emergencies The County shall train correctional officers to recognize and
respond to medical and mental health emergencies and shall ensure that inmates with emergency medical or mental health needs receive timely and appropriate care within the facility, and are promptly referred and transported for outside care when the facility is unable to provide appropriate care.
Continuity of Care and Access to Outside Providers 61. Recovering Inmates and Inmates Unable to Care for Themselves The County shall ensure
that inmates who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. All inmates returning to the facility after surgery or hospital treatment and inmates who cannot care for themselves shall be seen immediately by medical staff and placed or treated as medically appropriate upon return .to the facility.
62. Access to Specialty Care The County shall ensure that inmates whose serious medical or
mental health needs go beyond the services available at the Detention Center shall receive
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timely referral to appropriate medical or mental health care professionals qualified to meet their needs. The County shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. Inmates awaiting outside care shall be seen by medical staff as medically necessary to evaluate the current urgency of the problem and respond as medically appropriate. The County shall seek to obtain records of care and diagnostic tests received during outside appointments in a timely fashion and include such records in the inmate's medical record or document the inmate's refusal to cooperate and release medical records. Following a visit to an outside specialist, medical staff, mental health staff, or a dentist shall review information and documentation available from the visit and provide reasonable follow-up care.
63. ·Mental Health Services Log The County shall maintain an updated log of inmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive medication. The log shall include each inmate's name, diagnosis or complaint, and next scheduled appointment.
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Chronic Diseases 64. Clinical Guidelines The County shall develop or adopt existing written updated clinical
guidelines for chronic diseases, consistent with nationally accepted guidelines, and implement such guidelines to provide appropriate diagnosis, monitoring, treatment and continuity of care.
65. Chronic Disease Log The County shall maintain an updated log of inmates with chronic illnesses. The County shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmate's individual medical record.
Treatment of Female Inmates 66. Treatment Guidelines The County shall implement nursing protocols concerning medical
care for women, including screening for pregnancy, and gynecological and obstetric care. The County shall implement timely and appropriate care for pregnant women as medically indicated, including discharge planning. The County will work with and refer pregnant inmates to community providers capable of developing individual treatment plans and assisting with discharge planning. In such cases, the County shall facilitate treatment planning and implement those responsibilities assigned to the County under the plan subject to reasonable security considerations.
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Drug and Alcohol Withdrawal and Detoxification 67. Drug and Alcohol Withdrawal Identification and Treatment The County will screen all
· incoming inmates for signs and symptoms of drug and alcohol withdrawal and ensure that all inmates demonstrating symptoms of drug and alcohol withdrawal are timely identified. The County shall provide appropriate treatment, housing and medical supervision for drug and alcohol withdrawal.
Medication Management 68. Access to Appropriate Medication The County shall ensure that inmates have timely
access to necessary medications for known serious medical1or mental health conditions. The County shall develop and implement a plan to ensure that off-formulary medications may be requested, approved, received, and administered within a reasonable period after determination by medical staff that such medication is medically necessary to treat a serious medical or mental health condition. The plan shall include a provision for expedited access to and administration of off-formulary medications when medically necessary. During the term ofthis Agreement, the County shall log all requests for approval of off-formulary medications, the dates of the request and approval or denial, the reasons for any denial, and the date the inmate began receiving the medication.
69. Delivery and Continuity The County shall ensure continuity of medication by ensuring regular and timely distribution and documentation of medication to all inmates, including:
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access to medication in emergencies and on weekends; contemporaneous documentation and monitoring of dosages dispensed and received and documentation of refusals and noshows; timely recording of medication records in patients' individual files; and recording and monitoring of medication errors. The County shall track refusals of medication and no-shows to be reviewed in its quality assurance program, and shall take appropriate corrective measures if the review evidences problems in medication distribution.
70. Prescribing Practices Only qualified medical staff shall prescribe medications. The only exceptions shall be following written protocols for immunizations or life-threatening emergencies. Except for renewals, inmate patients shall have a face-to-face evaluation by the prescribing clinician or designated health professional with prescriptive authority, within seventy-two (72) hours of the telephone prescription order, for medications prescribed for serious medical or mental health illnesses or symptoms.
71. Medication Administration Records The County shall provide for complete patientspecific medication administration records for all individually administered medications. For keep-on-person medications, the County shall record delivery of the medication. The County shall document inmates' refusal to take individual dose prescription medication or receive keep-on-person medication.
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72. Discharge Medication and Information When the County has advance notice of the discharge of inmates with serious medical or mental health needs from detention, the County shall provide such inmates with at least a seven (7} day supply of appropriate prescription medication, unless a different amount is medically appropriate, to serve as a bridge until inmates can arrange for continuity of care in the community. The County shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. The County shall prepare and send with transferring.·inmates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Detention Center. The County shall ensure that information about potential release or transfer of inmates is communicated to health services staff as soon as it is available to the County.
Mortality Reviews 73. Autopsy The County shall request an autopsy for every inmate who dies while in the
custody ofthe Detention Center.
74. Mortality and Morbidity Reviews The County shall conduct a mortality review for each inmate death while in custody and a morbidity review for all serious suicide attempts or other incidents in which an inmate was at high risk for death. Mortality and morbidity reviews shall involve physicians, nurses, and other relevant Detention Center personnel
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and shall seek to determine whether there was a pattern of symptoms which might have resulted in earlier diagnosis and intervention. The mortality and morbidity reviews shall analyze the circumstances surrounding the incident. The County shall obtain any autopsy reports and related medical data or shall document the unsuccessful attempts to obtain them. The County shall address any problems with care or access to care that occurred, through training, policy revision and any other appropriate measures.
Infection Control 75. Infection Control Plan The County shall implement an infection control program that
addresses blood borne and airborne hazards and infections spread through contact. The plan shall include provisions for the identification, treatment, and control of Methicillinresistant Staphylococcus Aureus ("MRSA") at the Detention Center. /
76. Training The County shall train staff and inmate workers regarding measures necessary to prevent the spread of blood borne and airborne pathogens and infections spread through contact.
77. Hazardous waste The County shall appropriately dispose of hazardous and medical waste.
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78. Laundry The County shall implement generally accepted environmental health standards for institutions for laundering inmates' clothing and linens in a manner that prevents spread of infection, including proper use of disinfectant.
B. SUICIDE PREVENTION 79. Policy The County shall revise existing suicide prevention policies as necessary to
include: (1) stafftraining; (2) identification and screening of potentially suicidal inmates; (3) appropriate housing for suicidal inmates; (4) effective watch procedures, durations and conditions of monitoring; (5) suicide intervention procedures; and (6) receipt and transmission to appropriate persons of reports of inmate suicidal behavior and information needed to protect suicidal inmates.
80. Training The County shall train clinical, mental health and correctional officer staff who have inmate contact regarding: (1) the warning signs and symptoms of inmates at risk of suicide; (2) why correctional environments are conducive to suicidal behavior; (3) highrisk suicide periods; (4) potential predisposing factors to suicide; (5) procedure and methods for responding to inmates who exhibit such risk; (6) observation techniques; (7)
I
searches of inmates who are placed on suicide watch; (8) emergency procedures for responding to a suicide attempt; (9) location and use of cut-down tools and other emergency response supplies; and (1 0) how to refer inmates with mental health needs for
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appropriate care. All facility staff that has inmate contact shall have initial training and refresher trainings annually.
81. Suicide Watch The County shall revise as necessary policy, procedures and practices to ensure that inmates placed on suicide watch are supervised sufficiently to maintain their
an safety and to address the following requirements. When staff initially places inmate
on observation, the inmate shall be strip searched and monitored until a mental health professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. On a case-by-case basis, it may be acceptable to order the housing of two suicidal inmates in the same cell. Until such assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients. Mental health staff shall provide servic~s initially as soon as possible an~ then as medically appropriate to all. inmates on suicide watch Monday through Friday. ·Mental health trained registered nurses may provide this function on weekends. On-call mental health staff shall respond as necessary to provide care to inmates newly placed on suicide watch on the weekends. Inmates shall only be removed from suicide watch after approval by mentalhealth staff after a suicide risk assessment indicates it is safe to do so. Mental health staff shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. The County shall revise observation logging procedures and practices to ensure that sufficiently detailed information about an inmate's suicide watch is recorded at appropriate intervals. At the time of placement on suicide watch, medical or
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mental health staff shall write orders setting forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils. These conditions shall be altered only on the written instruction of the mental health staff, except under emergency circumstances.
82. Risk Assessment The County shall ensure that any inmate showing signs and symptoms of suicide is assessed using an appropriate suicide risk assessment instrument.
C. SECURITY AND SAFETY Inmate Supervision 83. Correctional personnel The County shall staff the master control center; each housing
unit, including administrative and disciplinary segregation; booking; the kitchen area and the medical area with adequate correctional personnel.to protect inmates from unreasonable risks of harm. At all times, the master control center shall be staffed by at least two correctional officers and each housing unit control center shall be staffed by at least one correctional officer. Staff may be aided by appropriate monitoring equipment maintained in working order.
84. Monitoring equipment The County shall maintain in working order all monitoring equipment at the Detention Center.
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Grievances and Investigations 85. Filing of grievances The County shall develop and implement an effective inmate
grievance system, ensure that grievances may be filed confidentially where the filing of such grievance might expose the inmate or a third party to imminent danger. The County shall also ensure that grievances receive appropriate follow-up, including informing the grievant of its outcome and tracking implementation of resolutions.
86. Investigations The County shall develop and implement policies, procedures and practices regarding internal investigations to ensure that management has a mechanism for identifying problems and appropriate remedies. The County shall maintain staffing suffi~ient to meet such internal investigation responsibilities.
Booking Area 87. Safety The County shall provide for the safety and security of inmates in the booking
area. The booking area shall not be used for protective custody, administrative segregation, disciplinary segregation or other special custody status detention, absent emergency circumstances, but may be used for tempora.rY detention of intoxicated individuals pursuant to New Mexico Statutes Annotated (NMSA), NMSA 1978 §§ 43-22 through 43-'-2-22.
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88. Hygiene The County shall provide inmates detained in the booking area with appropriate shower opportunities and shall document when the inmates are offered the opportunity to shower.
Inmate Classification System 89. Classification System The County shall develop and implement an appropriate
classification system to protect inmates from unreasonable risk of harm. Inmates shall be timely classified and placed in housing appropriate for security and safety. The County shall use best efforts to anticipate periods of unusual intake volume and schedule sufficient classification staff to timely classify inmates.
Information Regarding Constitutionally Required Services 90. Access to Information Regarding Constitutionally Required Services The County shall
ensure that newly admitted inmates receive information they need to comply with facility rules and regulations, be protected from harm, report misconduct, access medical and mental health care and seek redress of grievances.
D. QUALITY MANAGEMENT 91. Quality Assurance System The County shall develop and implement quality assurance
policies, procedures and practices to evaluate and make necessary changes to medical and mental health care, suicide prevention, security and safety at the facility.
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E. STAFF TRAINING AND SUPERVISION 92. Training Regarding this Agreement The County shall provide training and supervision to
staff sufficient to implement the provisions of this Agreement.
V. REPORTING REQUIREMENTS AN]) RIGHT OF ACCESS 93. The County shall submit quarterly compliance reports to the United States no later than
January 15, April15, July 15 and October 15 during the term of this Agreement.
94. Each compliance report shall describe the actions the County has taken since the date the last report was due to implement this Agreement, and shall make specific reference to the Agreement provisions being implemented.
95. The County shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the SFCADC at all reasonable times for inspection and copying by the United States. In addition, the County shall maintain and submit upon request records or other documents to verify that they have taken such actions as described in their compliance reports (e.g., census summaries, policies, procedures, protocols, training materials, and incident reports) and will also provide all documents reasonably requested by the United States.
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96. The United States and its attorneys, consultants, and agents shall have unrestricted access to the Detention Center, Detention Center inmates, Detention Center staff (including staff at SFCADC employed by any other outside medical services provider), and documents as reasonably necessary to address issues affected by this Agreement.
97. Within thirty (30) days of receipt of written questions from the United States concerning the County's compliance with the requirements of this Agreement, the County shall provide the United States with written answers and any requested documents.
98. The County shall appoint a settlement Compliance Officer to oversee compliance with this Agreement and to serve as a point of contact.
VI. MONITORING AND ENFORCEMENT 99. Compliance Monitoring DOJ representatives, including its experts, may conduct at least
four on-site compliance monitoring tours, subject to fiscal feasibility. The dates and duration of each on-site compliance monitoring visit shall be determined by DOJ representatives in consultation with the County. The County shall provide DOJ representatives with reasonable access to inmates and staff, documents, and information relating to implementation of this Agreement. DOJ shall have the right to conduct confidential interviews with inmates, and to conduct interviews with facility staff outside the presence of other staff or supervisors, and the County's experts shall be permitted to
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participate in these interviews. To the extent that the County proceeds in good faith to implement the terms outlined in this Agreement, DOJ shall conduct exit interviews on the final day of each monitoring tour and shall provide the County with written reports completed by DOJ experts regarding the Detention Center. The DOJ shall identify any deficiencies promptly following the monitoring tours. If, after indentifying deficiencies identified during the monitoring tours, the United States maintains that the County has failed to carry out any requirement of this Agreement, the United States shall notify the County of any instance(s) in which it maintains that the County has failed to carry out the requirements of this Agreement. The County may submit relevant additional information to the DOJ, including, but not limited to; reports of its own experts concerning the identified deficiencies. The submissions of the County will be considered by the DOJ.
100. Scope of Compliance Neither the United States nor its experts shall add provisions or expand the scope of this Agreement in any manner.
101. Non-compliance The County shall take substantial steps to correct a claim by DOJ pursuant to provision 99 within a reasonable time but in no event more than 90 days from receipt of a notice of non-compliance. During the 90 days following receipt of a notice of deficiency, the United States and the County shall coordinate and discuss any areas of disagreement and attemptto resolve outstanding differences. If the United States and the County fail to reach an agreement, the DOJ may file a motion to enforce that provision of
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the Settlement Agreement that was the subject of the notice of deficiency by appropriate motion to the Court. The United States shall give the County fourteen (14) calendar days' written notice of its intent to file a motion before filing the motion, during which time, the County shall have the opportunity to cure the deficiency. The time periods set out in this provision shall not apply to any claim by DOJ pursuant to provision 99 that conditions or practices at the SFCADC pose an immediate and serious threat to the life, health, or safety of SFCADC inmate(s), in which the situation shall be corrected immediately.
102. Inmate Deaths The County shall notify the United States immediately upon the death of any SFCADC inmate (either in the Detention Center or following transfer from the Detention Center to a hospital) and shall forward to the United States copies of any completed incident reports related to death, autopsies and/or death summaries of residents, as well as all final reports of investigations that involve inmates' deaths.
103. Confidentiality Any information or documents obtained pursuant to this Agreement shall not be disseminated, except as provided by law, to any person not a party (or an employee or contractor of a party) to this Agreement. In the event of a request under the Freedom of Information Act ("FOIA"), or any other statute or provision of law, by a third party for disclosure of any information or documents provided by the County to the United States, the United States will assert all applicable exemptions from disclosure permitted by law.
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Additionally, the United States will notify the County of any such request if the United States intends to disclose any documents.
VII. IMPLEMENTATION AND TERMINATION 104. The County shall begin implementing all the terms ofthis Settlement Agreement
immediately upon the filing of this Agreement with the Court.
105. Except where otherwise specifically provided, the County shall complete implementation of all provisions of this Agreement within 180 days of the entry of this Agreement.
106. The effective date ofthis Agreement shall be November 1, 2007, and the Agreement shall terminate two years from its effective date.
107. The Agreement may terminate earlier than the two year period if the County has substantially complied with each of the provisions of the Agreement and has maintained substantial compliance for at least one year. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of sustained noncompliance shall not constitute substantial compliance.
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108. The Agreement may terminate earlier as to a particular provision of the Agreement if the County has substantially complied with the provision in question and has maintained substantial compliance for at least one year. However, the Agreement shall terminate as to the following, specific provisions if the parties confirm that SFCADC has maintained substantial compliance as to the specific provision during the first two successive compliance monitoring visits following execution of this Agreement: provisions 14, 42, 51, 68, 69, 72, 77, and 84.
109. After substantial compliance with all provisions of this Agreement for a period of one year, or after substantial compliance with a particular provision of this Agreement for a
a period of one year, the DOJ and the County will execute a Termination of Agreement or
Partial Termination of Agreement that confirms the commitments contained in this Agreement have been satisfied and which relieves the parties from further monitoring and reporting. The termination document shall contain the following statement: "The DOJ agrees that termination of this Agreement is appropriate. There is no current pattern or practice of the County or its contractors violating the inmates' constitutional rights addressed in our Agreement at the Santa Fe County Adult Detention Center."
110. If the County disagrees with findings of the DOJ as to its compliance with the terms of the Agreement, the County may file a motion to enforce the Agreement with the Court, but only after providing the DOJ, within 90 days, of notice of its intent to file such a
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 40 of 46
motion, during which period the DOJ and the County shall coordinate and discuss the areas of disagreement and attempt to resolve the outstanding differences. If the United States and the County fail to reach an agreement, the County may file a motion to enforce the term of the Agreement that was the subject of the notice of deficiency, by appropriate motion to the Court.
111. The County may a,t its option submit to the United States a written certification of substantial compliance with any substantive provision(s) of this agreement by facsimile or overnight delivery. The certification shall provide evidence of compliance. If representatives of the United States do not provide written objection to such certification within forty-five (45) calendar days of receipt, the County will be deemed in substantial compliance with the specified provision(s) beginning on the date of delivery of the certification.
112. Failure by either party to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.
113. If any unforeseen circumstance occurs that causes a failure to timely carry-out any requirements of this Agreement, the County shall notify the United States in writing within 20 calendar days after the County becomes aware of the unforeseen circumstance
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and its impact on the County's ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
114. In the event that any provision ofthis Agreement is declared invalid for any reason by the Court, said finding shall not affect the remaining provisions of this Agreement.
VIII. STIPULATION PURSUANT TO THE PRISON LITIGATION REFORM ACT,
18 u.s.c. § 3626
115. For the purposes of this Agreement only and in order to settle this matter, the Parties stipulate that this Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a). The Parties further stipulate and agree that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights alleged by the United States, is the least intrusive means necessary to correct these alleged violations, and will not have an adverse impact on public safety or the operation of a criminal justice system. Accordingly, the Parties agree and represent that the Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a).
116. The issue of liability has not been litigated. The County denies all allegations of the United States that violations of federal rights exist.
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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 42 of 46 117. This Agreement is not intended to have any preclusive effect except between the Parties.
Should the issue of the preclusive effect of this Agreement be raised, the Parties agree to certify that this Agreement was intended to have no such preclusive effect.
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Case 1:08-cv---0-0-·2-12-MCA-RH--S- ----·-··- ~---------:-··-----······-

- ....... ---·-···~

-D--o-c·-u·m-···e--·n- t.. 5-1 --·- .. -

Filed 03/06/08

Page 43 of 46

I

FOR THE UNITED STATES:

:GREGP.RY:.~J. ;; .:.FOURATT United States Attorney District ofNew Mexico
~~lt~-~ ·F~lea Electronically 3/6/08 JAN ELIZABETH MITCHELL Assistant U.S. Attorney P.O. Box 607 Albuquerque, NM 87103 505.346.7274. Jan.mitchell@usdQj .gov

~acp~/kc~ GCE CHUNGECKER Acting Assistant Attorney General Civil Rights Division
Chief · Special Litigation Sectiol\

KERRYKRENTLERDEAN SHERIDAN L. ENGLAND Tnal Attorneys u.s~ Department of Justice Civil Rights Division . Special Litigation Section 950 Pennsylvania Ave., NW . Washington, D.C. 20530

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Case 1:08-cv-00212-MCA-RHS Document 5-1 Filed 03/06/08 Page 44 of 46

FOR THE COUNTY:

--
Santa Fe County Board. of County Commissions
r~ i"ta Fe CoU!lty Manager ,.

~>kt/,..__( .,(.95)
/STEPHENC:ROSS
Santa Fe County Attorney

.~~'riik-=·

. Director

_.- ·

.Corrections Department

Santa Fe County

.·~

DAVIDTRiJ LO
Jail Administrator Santa Fe County Adult Detention Center

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APPENDIX A Medical staffing: Nursing 12 hours on-site registered nurse coverage daily. Mid-level practitioner Minimum of 40 hours per week on-site nurse practitioner or physician's assistant. Scheduling ofhealth services staff Hours of registered nurses, nurse practitioners and physicians' assistants shall be scheduled so that at least one of those professionals is at the facility 16 hours per day, five days per week, during the hours when there is the most inmate activity. The remaining eight hours of each weekday and the remaining 12 hours per day on weekends may be covered by Licenses Practical Nurses. Medical Director Minimum of 16 hours on-site physician per week, or, in the alternative, medical director is on-site at the facility at least portions of four days per week. Medical Director must fulfill all responsibilities outlined in provision 38. Physician Minimum of 16 hours on-site physician per week, or, in the alternative, physician is on-site at the facility at least portions of four days per week. Physician must fulfill all responsibilities outlined in provision 40. Physician emergency on-call 24-hour daily on-call physician coverage.
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Mental Health Staffing: Psychiatrist Minimum of 20 hours of on-site psychiatrist per week, or, in the alternative, on-site psychiatrist at least portions of three days per week. Psychiatrist must fulfill all responsibilities outlined in provision 39. Psychiatrist emergency on-call 24-hour daily on-call psychiatrist coverage. Mental Health Professionals Minimum of regular coverage by one full-time and one half-time Mental Health Professional. Daily mental health staff must be present from 8 a.m. to 5 p.m. Monday through Friday. On-call Mental Health Coverage 24 hours on weekends
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 March 6, 2003
Mr. Jack Sullivan County Commission Chairman 102 Grant Avenue Santa Fe, NM 87501
Re: Santa Fe County Adult Detention Center (Formerly the Santa Fe County Correctional Facility)
Dear Mr. Sullivan:
We write to report the findings of our investigation of conditions at the Santa Fe County Adult Detention Center ("Detention Center," formerly the Santa Fe County Correctional Facility). On March 20, 2002, we notified you of our intent to investigate the Detention Center pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997.
On May 7-10 and 29-31, 2002, we conducted on-site inspections of the facility with expert consultants in corrections, medical care, mental health care, and sexual misconduct/gender issues. While at the Detention Center, we interviewed correctional and administrative staff, inmates, medical and mental health care providers, and programming, training, safety, food service and sanitation personnel. Before, during and after our visit we reviewed an extensive number of documents, including policies and procedures, incident reports, medical and mental health records, inmate grievances, use of force records, and investigative reports.
We commend the staff of the facility and the County for their helpful and professional conduct throughout the course of the investigation. The staff have cooperated fully with our investigation and have provided us with substantial assistance.
Consistent with the statutory requirements of CRIPA, we write to advise you of the results of this investigation. As described more fully below, we conclude that certain conditions at the Detention Center violate the constitutional rights of inmates. We find that persons confined suffer harm or the risk

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of serious harm from deficiencies in the facility’s provision of medical and mental health care, suicide prevention, protection of inmates from harm, fire safety, and sanitation. In addition, the facility fails to provide inmates sufficient access to the courts and opportunity to seek redress of grievances.
I. BACKGROUND
A. FACILITY DESCRIPTION
Santa Fe County opened the Detention Center in 1998. Management and Training Corporation (“MTC”), a private corporation, has managed and operated the facility by contract with the County since October 2001. The facility has a housing capacity of approximately 672 inmates. On the first day of our visits to the facility, the total inmate population was 598. There were 532 adult male and 66 adult female inmates. At the time of our visits, the Detention Center housed inmates from nineteen jurisdictions, including federal inmates by agreement with the Bureau of Indian Affairs and the United States Marshals Service. Since that time, the facility has entered into a contract to house a large number of inmates from the State of New Mexico Department of Corrections, as well.
Inmate housing includes double cells and dormitories. Some inmates are singly housed in double cells. Housing is divided into four housing unit pods of six areas each, centrally managed by a unit control center. The Detention Center also has administrative areas, classrooms, a booking and intake area, four outdoor recreation yards, food service, laundry and medical facilities. Physicians Network Associates (“PNA”) provides the medical care at the facility by subcontract with MTC.
B. LEGAL BACKGROUND
CRIPA gives the Department of Justice authority to investigate and take appropriate action to enforce the constitutional rights of inmates in jails and prisons. 42 U.S.C. § 1997.
With regard to sentenced inmates, the Eighth Amendment’s ban on cruel and unusual punishment "imposes duties on [prison] officials, who must provide humane conditions of confinement; prison officials must ensure that inmates receive adequate food, clothing, shelter, and medical care." Farmer v. Brennan, 511

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U.S. 825, 832 (1994). Prison officials have a further duty "to protect prisoners from violence at the hands of other prisoners." Id. at 833. The Eighth Amendment protects prisoners not only
from present and continuing harm, but from the possibility of future harm as well. Helling v. McKinney, 509 U.S. 25, 33 (1993). It also forbids excessive physical force against prisoners. Hudson v. McMillian, 503 U.S. 1 (1992). Medical needs which must be met include not only physical health needs, but mental health needs as well. Bowring v. Godwin, 551 F.2d 44, 47 (4th Cir. 1977); Young v. City of Augusta ex rel Devaney, 59 F.3d 1160 (11th Cir. 1995).
With regard to pre-trial detainees, the Fourteenth Amendment prohibits imposing conditions or practices on detainees not reasonably related to the legitimate governmental objectives of safety, order, and security. Bell v. Wolfish, 441 U.S. 520 (1979). The Fourteenth Amendment also requires that inmates have access to the courts, sufficient to challenge their sentences and the conditions of their confinement. Bounds v. Smith, 430 U.S. 817 (1977); Lewis v. Casey, 518 U.S. 343 (1996).
II. FINDINGS
A. MEDICAL CARE
The Detention Center provides medical services through a subcontract between MTC and Physicians Network Associates (“PNA”). The Detention Center, through PNA, provides inadequate medical services in the following areas: intake, screening, and referral; acute care; emergent care; chronic and prenatal care; and medication administration and management. As a result, inmates at the Detention Center with serious medical needs are at risk for harm.
1. Intake, Screening, and Referral
PNA’s intake medical screening, assessment, and referral process is insufficient to ensure that inmates receive necessary medical care during their incarceration.
According to PNA policy and in keeping with the standard of care in jails, all arrestees should receive an initial health screening at the time of booking. At the Detention Center, screenings are completed by a Licensed Practical Nurse (“LPN”) following a three-page form, and include a physical, mental, and

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dental health screen. The intake process is intended to ensure that inmates who suffer from chronic conditions or otherwise need prompt medical attention are referred to the Health Services Unit for needed follow-up care and given appropriate housing.
Review of a random sample of medical records of inmates admitted during the month of April 2002, revealed that 20 percent did not have the documented initial health screening described above. Without this screening, incoming inmates suffering from chronic and/or contagious disease may not be referred for followup care, which heightens the risk that their illnesses will continue and their conditions will deteriorate. Furthermore, incoming inmates whose illnesses go undiscovered and untreated may be housed with the general population, placing other inmates and staff at risk for disease.
Moreover, even when PNA staff identify inmates with serious medical needs during the intake process, they fail to refer them for appropriate care. Chart review revealed that of those inmates in our sample who did receive the initial health screening, none were referred to the Health Services Unit for the medical attention they needed. For example, inmates reporting histories of hypertension and depression who claimed to be on prescription medication at the time of their incarceration should have been promptly referred to the Health Services Unit for assessment, decisions about continuity of medication(s), and appropriate medical care. Interruption of hypertension medication can lead to heart ailments and strokes, and interruption of antidepressant medication can lead to mental health crisis as well as resulting in physical withdrawal symptoms such as headache, disturbed sleep and loss of appetite. Failure to refer for medical follow-up inmates who have chronic or acute conditions may result in the interruption of treatment and medication, which may in turn lead to deterioration or loss of function.
Subject to reasonable security needs, screening interviews must be conducted privately, to ensure that the inmate feels comfortable enough to disclose any physical or mental health problems she or he may be experiencing. During our visit, we observed breaches of confidentiality of inmate medical and mental health information. Two different male corrections officers, on

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separate occasions, entered the room where a newly admitted female inmate was completing the initial health screening and observed parts of the process. One of the male officers handcuffed the inmate. The officers’ presence and the imposition of unneeded restraints on a cooperating inmate decreases the likelihood that the inmate will provide reliable information during the screening. Accurate medical history is critical to the provision of appropriate care and protection of other residents and staff from communicable diseases.
To provide for inmates' serious medical needs, facilities must identify inmates with chronic, acute or contagious conditions or other serious needs so that appropriate care may be provided. Accordingly, inmates who stay more than a few days at a facility must have a detailed assessment of their health histories and current conditions beyond the limited information provided in the intake health screening. Such steps are necessary so that plans for inmates' ongoing care may be established. The facility fails to conduct timely histories and physicals to ensure that medical providers have adequate information to meet inmates' serious medical needs.
Our review indicated that only 37 percent of the inmates received a full health appraisal within 14 days of arrival at the facility. Only 50 percent of the records in our sample contained documentation that the health appraisal or the skin test for tuberculosis were completed within 18 days of admission. In some files in which a health appraisal was recorded, documentation was incomplete, and failed to include information on the inmate’s history, a review of symptoms and/or a record of the physical examination. In some cases we reviewed, PNA staff failed to respond appropriately to information received from inmates during the 14-day evaluation, including information which indicated a serious medical need. The nurses conducting these examinations have no formal training in physical assessment.
For example, one inmate reported during his 14-day physical that he had tested positive for glaucoma at the facility from which he was being transferred. Although a note was placed in his chart to procure the records of this test, PNA failed to follow through and staff never obtained the records. The inmate complained about his condition again nearly two months later, but still did not receive an eye examination. Another four months passed between the inmate’s second request and our site visit to the Detention Center, at which point our expert reviewed this

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inmate’s medical record and reported his concern to the staff. Nearly one month after our visit, the patient finally received an eye examination. However, there was still no report of an ocular pressure determination or any other test to detect glaucoma. If this inmate has glaucoma, he may become blind unless he receives treatment. As of our last review of his chart, it had been eight months since he originally reported this condition during the initial health screening, and his record still did not reflect an appropriate assessment to determine what care he needed.
PNA does not test for sexually transmitted diseases (“STDs”). STDs are prevalent in jail populations. Left untreated, STDs can cause brain and organ damage and damage to fetuses. PNA’s failure to screen for STDs places the inmates and the community at risk.
2. Acute Care
PNA fails to provide timely access to appropriate medical care for inmates when they develop acute medical needs. Medical care is unreasonably and unnecessarily delayed and, even when provided, often inadequate.
Inmates access medical care by completing sick call forms, which are filed in boxes on the housing pods. A designated member of the Health Services Unit staff retrieves the sick call forms daily. PNA policy provides that the requests will be “triaged,” and inmates will receive medical care according to the urgency of their medical needs. The Health Services Unit calls for the inmate if a visit to the Unit is deemed necessary.
Our review of inmate sick call requests revealed that inmates experience delays in responses to their requests for care, putting them at risk for worsening conditions. For example, one inmate filed a sick call request stating that he was suffering from alcohol and narcotic withdrawal symptoms, including cold sweats and vomiting. PNA policy states that an inmate exhibiting symptoms of withdrawal such as sweating and vomiting will be evaluated by a Health Services staff person as soon as possible. This inmate was not seen for four days, even though withdrawal from alcohol can be life-threatening.
Even once inmates succeed in getting to the Health Services Unit, they frequently receive substandard care. We reviewed the medical records of ten inmates seen for primary care by the nurse practitioner within a one-month period. Six of the ten inmates received substandard care. For example, two inmates had abnormal

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skin tests for tuberculosis, one of whom was recently infected, but neither was offered treatment. The consequences of failing to treat new latent tuberculosis infection can be severe, as recently infected individuals are at a high risk of developing contagious tuberculosis. This risk can be significantly reduced with prophylactic treatment. The nurse failed to recognize abnormal heart rhythm in one inmate, and in a second inmate, identified abnormal heart rhythm but failed to refer that inmate to a specialist for appropriate examination.
Additional chart reviews confirmed PNA’s failure to respond to inmates’ acute medical needs. For example, one inmate reported breast lumps and lumps in her armpit, chest pain, and swelling in her legs and feet. Although a mammogram was ordered in October 2001, it had not been done by the time of our visit to the Detention Center seven months later. In addition, by that
time the swelling in this inmate’s legs was so severe that when pressed, her tissue stayed depressed, resembling “silly putty.” This condition is known as “pitting edema” and, as our expert reported to the PNA staff, requires urgent medical care. Pursuant to our recommendation, this inmate was subsequently seen by a physician. However, the physician did an incomplete evaluation of her swollen legs and did not document whether he conducted an evaluation of her breast or armpit lumps.
Another inmate who had heart disease and a history of positive skin testing for tuberculosis complained of chest pain. The nurse practitioner treated him with nitroglycerin. After two months, the inmate was sent to the emergency room, where the physician recommended a chest x-ray, a stress test, and treatment with long-acting pain medication, none of which the inmate received. Three months later, the inmate developed fever, chills and an elevated respiratory rate. The nurse practitioner did not examine the inmate or order a chest x-ray, which would be the standard of care for a patient with a positive skin test for tuberculosis complaining of these symptoms. Instead, the nurse practitioner diagnosed the inmate with pneumonia and prescribed antibiotics through a telephone call with health services staff, which is inconsistent with accepted standards of care. She did not see the inmate until three days later. The failure to diagnose and treat this inmate in an appropriate manner on a timely basis, despite the fact that he could have had tuberculosis, placed the inmate at serious risk. Furthermore, the failure to place this inmate in respiratory isolation based

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on the possibility that he was infected with tuberculosis placed the inmates and staff at risk for contracting the disease.
The grievance system does not provide an avenue for resolving problems of access to health services. The grievances we reviewed included a complaint from one inmate who was supposed to have an x-ray, but had received no response from the Health Services Unit despite having filed two grievances in three weeks. This complaint was not reviewed for eight days after it was filed, and no resolution to the grievance is documented. Another inmate filed a grievance complaining that he had not received his medication and that his condition was worsening. According to the response record, the matter was not resolved for eight days.
The nurse practitioner’s personnel file included a memo from the Vice President of Operations of PNA instructing her to see one patient for each five minutes of scheduled clinical time. Many inmates, particularly those with acute or chronic conditions, require significantly more clinical attention to ensure that their needs are adequately addressed. This arbitrary
time limit places extreme pressure on the nurse practitioner and necessarily affects the care she is able to provide. It also increases the likelihood that the nurse practitioner will fail to diagnose, will incorrectly diagnose, and/or will fail to provide appropriate treatment and prescribe correct medications to inmates with medical needs.
At the time of our visit, the only physician providing supervision or care at the Detention Center was the doctor who is the Chief Executive Officer (CEO) of PNA and is based in Lubbock, Texas. As the CEO of PNA, this doctor has numerous responsibilities, including supervising the medical care at each of the facilities at which PNA provides care throughout the south and southwestern United States. This physician was visiting the Detention Center an average of once every six weeks, and saw only a few patients during each visit. While he is available by telephone for consultation, he does not visit the Detention Center frequently enough to provide adequate supervision. Given the deficiencies in care and other problems identified in this letter, additional physician supervision at the Detention Center is necessary.
3. Emergent Care
PNA fails to provide appropriate and timely care to inmates

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with emergent medical needs.
One case we reviewed involved an inmate who was referred to the Health Services Unit because he had bleeding from the ear following trauma. Bleeding from the ear typically indicates either a perforated ear drum or a basilar skull fracture. The nurse never provided or referred the inmate for a full ear examination or a neurological examination, and instead prescribed an addictive narcotic pain reliever which is an inappropriate treatment for these symptoms.
Another inmate entered the Detention Center with high blood pressure and diabetes. He reported sudden loss of vision on February 20, 2002. Diabetics are at an increased risk for disease of the retina and bleeding into the retina. Sudden loss of vision, particularly in the case of a known diabetic, constitutes a medical emergency, and the inmate should have been immediately referred for emergency care. He was referred to an optometrist, who measures eyes for eyeglasses, as opposed to an ophthalmologist, who specializes in diseases of the eye. The inmate was finally seen by an ophthalmologist on April 1, 2002, nearly six weeks after he lost his vision. Although the ophthalmologist immediately referred him to a retina surgeon, the
Detention Center did not transport him to the retina surgeon for nearly two more weeks. After examining the inmate, the surgeon identified the inmate’s condition as a medical emergency and called the Detention Center for permission to operate immediately. Nonetheless, the inmate did not receive the surgery for another ten days. Although this inmate’s blindness could have been prevented had he received appropriate care, the delay in treatment caused him to lose his vision permanently.
Another inmate, also with severe symptoms, was similarly unable to access appropriate care when he experienced a medical emergency. This inmate, who reported a history of head trauma at intake, became disoriented on his third day at the Detention Center. Three days later he experienced bowel and bladder dysfunction, exhibited abnormal movement in his extremities, and had difficulty balancing. After another three days, he became incontinent, was disoriented and experienced weakness in his left side. The facility finally sent him to the emergency room at this point. Head trauma can cause serious seizure disorders. Despite this inmate’s history of head trauma and his serious symptoms, neither the nurse practitioner nor the physician at the Detention Center ever examined him. This denial of treatment

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resulted in the worsening of the inmate’s condition.
4. Chronic Illness and Prenatal Care
Individuals suffering from chronic illnesses such as diabetes, hypertension, asthma, and HIV must be regularly monitored by medical professionals to ensure that their symptoms are under control and their medications are appropriate. PNA’s policies recognize its obligation to provide appropriate medical care for inmates with chronic diseases. Nevertheless, our review of the medical records of fourteen inmates known to have one of the four chronic diseases mentioned above revealed that PNA fails to provide adequate medical care to inmates with chronic diseases.
For example, appropriate care for individuals with hypertension requires that the individual’s blood pressure be brought under control by diet and prescribed medication. The medical records we reviewed, however, indicated that only 50 percent of the inmates with hypertension received such care at the Detention Center. The standard of care for individuals suffering from asthma requires the performance of a baseline peak flow measurement and, for those with persistent asthma, treatment with inhaled control medication and the provision of rescue medication. We reviewed medical records for four inmates with moderate persistent asthma. Of these four, only one had a
documented measurement of peak flow. None of the inmates had appropriate medication with inhaled steroids. Without this care, these inmates are at risk for persistent wheezing, bronchopneumonia, and life-threatening health crises. Of the five diabetic inmates whose charts we reviewed, none had documented measurements of A1C hemoglobin. This measurement is the only way to assess long term control of the disease. Furthermore, none of the diabetics had documented retinal examinations, which should be done annually. Such an examination might have prevented the loss of vision experienced by the diabetic inmate discussed in the preceding section.
The Detention Center fails to provide a medically appropriate diet for inmates with conditions that require the inmates to receive special diets. For example, the “heart healthy diet” provided to diabetics at the Detention Center contains approximately 30 percent more calories and fat than recommended for diabetics.

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PNA fails to provide adequate prenatal care for pregnant inmates. Of the four pregnant women at the Detention Center at the time of our visit, none had any prenatal visit with an OB/GYN during their incarceration documented, despite the fact that two of the women were in their third trimester of pregnancy and near term. While the pregnant inmates may have been seen by the nurse practitioner, they were not screened for diseases that can severely impact maternal and fetal health.
We reviewed the chart of one inmate who was within days of delivery at the time of our visit. This inmate reported a history of spontaneous miscarriages. She was within six weeks of delivery when she arrived at the Detention Center, and the nurse practitioner advised that she should be transferred to another facility better equipped to handle inmates with high risk pregnancies. This transfer never took place. Despite the nurse practitioner’s recognition of this inmate’s serious medical needs, the inmate was not scheduled for a prenatal visit with an OB/GYN until our expert reviewed her chart and advised the Detention Center staff that she needed additional prenatal care immediately. She was scheduled for a visit with an OB/GYN that week, and delivered one week later. This delay of care was deficient and placed the woman and her child at risk for serious harm.
5. Special Needs Care by Outside Providers
As discussed in the chronic care section above, Section A(4), the Detention Center fails to ensure that inmates receive timely referral to outside care providers when specialized care is medically necessary. In addition, our review indicates that approximately one in three outside care appointments that are arranged by medical staff are postponed or cancelled because of lack of available transportation officers.
Furthermore, the Detention Center fails to ensure that the recommendations of outside specialists, once consulted, are carried out upon the inmate’s return to the facility. We reviewed the charts of several inmates sent for outside care, and found no indication that PNA staff sought written documentation of results of the referrals or the recommendations and findings

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of the outside care providers. PNA does not employ any tracking method to follow the care received by inmates who are referred for outside specialty care. Without this information, the PNA providers cannot implement treatment recommendations made by the specialized care provider.
6. Medication Administration and Management
PNA fails to provide inmates with needed medications in a timely manner, and fails to monitor medication in inmates with serious medical needs.
The Detention Center fails to provide for continuity of medications for inmates upon arrival at the facility. Several files we reviewed revealed that the nurse practitioner does not continue the same medications for inmates that were prescribed for them prior to their incarceration. Sometimes the nurse practitioner simply discontinues the medication, and sometimes she changes the inmate’s prescription to older, less expensive medications which are significantly less effective. For example, inmates who entered the Detention Center with credible histories of taking medication such as Prozac and Wellbutrin were disadvantageously changed to doxepin, amitryptilyne and nortriptyline, which are significantly less effective than Prozac and Wellbutrin and have significantly more adverse side effects.
One inmate arrived at the facility with Navane in her possession. She reported that she has “psychotic features,” but had been stable for five years on low doses of Navane, an antipsychotic. Despite the fact that she arrived at the facility with her medication on her person, she did not receive the
medication for her first five days in the facility. She was switched to Mellaril, a non-equivalent drug, which the Federal Drug Administration has determined is not a first line antipsychotic. Because Mellaril is known to cause potentially fatal heartbeat irregularities, it is usually prescribed only when other antipsychotics have been tried and failed. Her treatment was not being monitored by the nurse practitioner or the counselor. Her cellmates confirmed that she frequently seemed distraught, and would cry, scream, and talk to herself. Failure to provide this inmate with her prescribed medication and to monitor her treatment on a different medication placed her at risk for psychotic relapse.

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PNA also fails to provide reliable access to medications that have been prescribed or continued by the nurse practitioner. Several inmates complained that they had not received prescribed medications despite repeated requests. Our chart reviews substantiated these complaints. For example, one HIV-positive inmate did not get his medication at the Detention Center for six weeks. The inconsistent use of medication contributes to the emergence of drug resistant diseases, which place both the individual and the community at risk.
Inmates also complained that they frequently missed their doses because they were not in their cells or did not hear the medication call. A review of the medication administration records revealed that approximately 25 percent of the entries were blank. PNA attributed these missed doses to inmate noncompliance. PNA policy requires that every refusal of medication will be documented in the inmate’s medication administration record (MAR), and after three refusals or no/shows, the medical staff will discuss non-compliance consequences with the inmate and document this counseling in the health record. Based on the charts we reviewed, PNA does not appear to be following its policy.
When certain medications are prescribed, such as anti-epileptic medications, it is necessary to check blood levels of these medications at regular intervals to ensure the inmate’s health is not at risk from either too high or too low a dosage. We found several instances in which PNA failed to monitor inmates on these types of medications, even when inmates reported experiencing side effects.
Even when staff did monitor medication levels, they failed to respond to indications that an inmate’s dosage was inappropriate. For example, an inmate had been prescribed a medication for his seizure disorder, in addition to several other
medications, and his blood levels of the seizure medication had been measured. Although the laboratory results showed that the amount of this drug in his system was not enough to achieve the intended therapeutic effect, there was no reference to this finding anywhere else in his medical record. Moreover, staff failed to respond appropriately, such as adjusting his medication. Seven days later, the inmate attempted suicide by cutting his wrists, then suffered a seizure. Even with all the attention from medical staff due to his suicide attempt, his seizure medication blood level was not measured until four days

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after his suicide attempt, at which point it was still well below the therapeutic range. Even then, staff did not address this deficiency for another three days, when his medication was finally adjusted.
Our review revealed that the Detention Center uses protocols to guide nurses in the treatment of illnesses that include some standardized orders for prescription of medications. This includes a protocol for treatment of inmates experiencing substance abuse withdrawal. Allowing nurses administer the medications to inmates without review by the nurse practitioner or physician and without an evaluation of the inmate’s particular medical needs is unsafe.
PNA’s formulary does not contain effective medication for inmates with serious medical needs such as hypertension, heart failure and diabetes. In addition, the formulary includes many less expensive, less effective medications than are currently available for the treatment of some diseases.
The facility claims that there is a waiver process in place by which medical practitioners can prescribe medications off the formulary, but the medical staff was unable to provide us with policies or forms providing for such waiver. Approval from corporate headquarters is necessary to prescribe an off-formulary medication. This cumbersome and unstandardized process combined with the severe understaffing at the facility make it less likely that overburdened staff will make the effort to prescribe a drug off-formulary. Although we did note that some inmates were receiving off-formulary medications, they were few and far between. Some inmates at the Detention Center are currently provided with less effective medications with greater side effects than they had received prior to incarceration, which can lead to deterioration in inmates with mental illness and endorgan damage in inmates with diseases such as hypertension and diabetes.
At the time of our visit, all medications, including psychotropic medications, were prescribed by the nurse practitioner. As the only person on the medical staff with the ability to prescribe medication, the nurse practitioner is overburdened. She frequently prescribes, adjusts or terminates psychotropic medication on the recommendation of the mental health counselor, sometimes without examining or even seeing the

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inmate. Neither the counselor nor the nurse practitioner is trained to manage medication of inmates with complex mental health diagnoses, such as schizophrenia and bipolar disorder. Furthermore, the counselor has made it widely known that he is personally opposed to the use of psychotropic medication. Several inmates with credible histories of stabilization on psychotropic medications reported that the counselor told them they did not need medications and that they should take control over their own problems. The counselor is not trained nor licensed to make medical prescription decisions. Allowing him to function in this capacity increases the risk that inmates with mental health needs will not receive needed medication. We understand that shortly after our visits, the facility retained the part-time services of a psychiatrist, which may have alleviated some of this problem.
B. MENTAL HEALTH CARE
The Detention Center fails to provide adequate mental health services to inmates who need this care. Specifically, the Detention Center fails to provide appropriate intake screening and referral and access to mental health care.
1. Intake Screening and Referral
PNA’s initial health screening process, which is discussed in detail in section A(1) above, includes a brief mental health assessment. Nurses ask inmates questions concerning their mental health treatment history, medication, and mental health status. This assessment may result in a referral for either a routine mental health evaluation or an immediate evaluation by the mental health practitioner and determination whether the inmate will receive follow-up mental health care.
Our review indicates that PNA does not identify appropriately inmates who may need an immediate mental health evaluation and mental health services. For example, one inmate answered several of the initial mental health suicide screening questions in the affirmative, including that he had recently experienced a significant loss, that he felt that he had nothing
to look forward to, and that he “just didn’t care.” He reported that he had been diagnosed with Post Traumatic Stress Disorder and that he was taking an antidepressant for this condition. He also stated that he felt that he needed to see a psychologist.

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Despite these indicators, the screening nurse concluded that the inmate needed only a routine mental health referral, as opposed to an immediate mental health evaluation and determination whether mental health services were necessary. This inmate’s suicide two weeks later is discussed in greater detail in the section on suicide prevention, below.
As this inmate’s experience illustrates, PNA’s failure to identify and refer appropriately inmates with immediate mental health needs may be partially attributed to the fact that the threshold for triggering such a referral is too high. The form used to guide the nurses requires too many indicators to be present before directing referral. Inmates reporting suicidal ideation, a history of recent suicide attempts, psychiatric hospitalization, and/or recent or current use of psychotropic medication should be referred for a mental health assessment when booking is completed. However, chart reviews indicate that inmates reporting these symptoms during the initial health screening are not consistently referred for immediate assessment by a mental health professional.
Moreover, some inmates reporting significant mental health histories do not receive referrals for mental health services at all. For example, one inmate arrived at the facility on a mood stabilizing medication and an antidepressant. These medications were verified at intake. During the initial health screening, the inmate reported a two-year history of mental health problems, including a suicide attempt. Despite her verified medications and her mental health history, the intake nurse did not refer this inmate for mental health services.
Other inmates who receive a routine mental health referral are not seen by a mental health practitioner in a timely manner. Inmates reported a significant time lag between the referral and their first visit with the mental health services provider. Chart review confirmed these reports. Inmates who received routine mental health referrals might wait two weeks or more to see a provider after the initial referral was made.
Some inmates may develop symptoms of mental illness following incarceration, but not seek care. The 14-day physical examination is an opportunity for nurses to detect inmate mental health needs that have arisen since the time of admission. However, nurses conduct no mental health assessment at the 14-day physical.
The mental health evaluations conducted at the facility do

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not incorporate development of a diagnosis or treatment plan, and are therefore inadequate. The form which guides this evaluation fails to provide for an ultimate determination that an inmate has a mental disorder, and contains no reference to a diagnosis of the disorder. This information is important because it forms the basis for the provider’s decision to place the inmate on the mental health roster for services. It also functions as the basis upon which a treatment plan may be developed for the inmate. In the absence of such documentation, it is difficult to assess whether some inmates referred for mental health care are receiving appropriate care. The facility does not engage in discharge planning for inmates receiving mental health services.
2. Access to Adequate Care
The mental health care provided at the Detention Center is inadequate to meet the needs of inmates with serious mental health conditions. At the time of our visit, mental health services at the facility were provided by a master’s level counselor, who is not trained to diagnose psychiatric illness nor licensed to prescribe medication. The facility’s problems with medication management are outlined above in section A(5).
One chart we reviewed contained a particularly severe example of the potential consequences of failing to provide access to adequately trained mental health staff and appropriate mental health care. This inmate arrived at the facility with a documented history of prior treatment at the Detention Center for bipolar disorder and depression. The facility’s former staff psychiatrist had diagnosed the inmate with depression during a previous period of incarceration and treated her with medications. Review of her chart indicates that shortly after MTC/PNA took over management of the Detention Center, the inmate was taken off some of her medications based on the counselor’s note that “she and I decided she didn’t want to take the Paxil and vistorel.” The counselor’s written notes document that this inmate subsequently declined over a period of the next three months, including banging on the metal portion of her bed and singing along aloud; destroying her mattress with a razor blade; and flooding her cell with water. She was placed in administrative segregation several times during this period. Both the counselor’s notes and the inmate’s sick call requests document that throughout this period, the inmate repeatedly requested a return to her previous medications, but the counselor denied her requests. The inmate’s decline ultimately resulted in a suicide attempt.

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During subsequent periods of incarceration the counselor noted that this inmate “attempted to convince [him]” that she needed medication for her “alleged” bipolar disorder but “unfortunately she wasn’t able to convince [him].” He denied her repeated requests for medication without consulting with any practitioner trained and licensed to make such decisions. Thus, this inmate who had been treated by a psychiatrist with psychotropic medications for many months was forced to attempt to conform her behavior in a jail environment without any aid from medication. She experienced continued headaches, anxiety, depression, and sleep disturbance, and frequently found herself in segregation.
Other inmates reported that this counselor instructed them to “Go smoke dope and you will be O.K.” and made other inappropriate comments in the course of counseling sessions. Such comments alienated some inmates, who had nowhere else to turn for counseling services. Furthermore, the facility had no mental health professional trained and skilled to provide services to victims of sexual assault. When we raised this issue during our exit conference, the County took immediate action and reports that inmates will now be transported to the Rape Crisis Center for services as needed.
C. SUICIDE PREVENTION
The Detention Center suicide prevention policies and practices are seriously deficient and suicidal inmates are at grave risk of harming themselves as a result. As of the time of our visit, during the seven months since MTC assumed management of the facility, there had been one completed suicide and seven attempted suicides. A review of these incidents reveals that the Detention Center staff fail to respond appropriately to inmates’ indications of mental health crises and possible suicidality.
The standard of care for suicide prevention requires timely identification of risk; adequate assessment of risk; monitoring high risk inmates, in special housing units if indicated; and referral to appropriate providers for needed care. Because identification and assessment are addressed in preceding sections of this letter, this section will focus primarily on the Detention Center’s provision of monitoring and appropriate housing to suicidal inmates, and referral for crisis mental health care.

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Our review indicates that the Detention Center fails to provide adequate monitoring for inmates who have been identified as suicidal. An illustrative example is the completed suicide that occurred at the facility in January 2002. Upon arrival at the facility, this inmate expressed feelings that there was nothing to look forward to in the future as well as other signs of suicidality. He asked to see a mental health professional, but was given only a routine referral and not put on any type of suicide precautions. Two days later, while the inmate awaited his first visit with a mental health professional, staff learned that he had written a last will and testament in his cell, and placed him on suicide watch. While he saw a counselor during his time on suicide watch, once he was released from the watch three days later, he received no mental health services for nine days, until he attempted to cut himself with a razor. He was seen by medical and mental health staff and placed on a suicide watch in the booking area. Orders were for a five-minute watch, but staff only checked the inmate every 15 minutes.
While on watch, the inmate made explicit statements and other indicators that he continued to have active plans to end his life. Statements and observations included: observation that the inmate attempted to hang himself with a sock (appropriately, staff did remove his clothes after this attempt); a statement to a crisis response counselor that he would hurt himself on an exposed nail in his cell in the booking area; threats to the nurse practitioner that he would “pull out his jugular;” observations by a nurse that he attempted to remove sutures to the cut he had inflicted on his neck; a staff member note that the inmate’s food tray contained chunks of padding from the foam wall (he ultimately created a foothold for himself to climb up to hang himself); observations that he was tearing up his suicide blanket; and a statement that he was “very claustrophobic. I’ll lose my mind in this cell.” Despite these indicators, the facility did not adjust either the frequency of or the location of the watch, or take other security measures to address the situation presented. Furthermore, the crisis response counselor who saw the inmate the day before his suicide determined that the booking area was not an appropriate location for this inmate and recommended that he be moved, but the facility did not follow this recommendation.
The watch log ended at 18:45 the night before the inmate’s

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death, and did not resume until the following day at 6:00 a.m., nearly twelve hours later. That entry was followed by a second entry at 6:15 a.m., and the log ended again, until a 9:40 entry in which the inmate is quoted as saying to staff, “if I find something I will do myself in.” The inmate committed suicide by hanging himself from a sprinkler head with a strip of his suicide blanket at approximately 9:50 a.m.
Another inmate attempted to communicate to a supervising officer his intention to kill himself by holding a note up to his segregation cell door. Despite this clear manifestation of his need for intervention, the officer did not respond and the inmate was later found trying to hang himself with a sheet. These incidents as well as staff interviews at the facility indicate that staff are insufficiently prepared to identify the signs of suicidality and respond appropriately.
The Detention Center lacks an appropriate location for housing high risk suicidal inmates. The inmate who completed his suicide was being held in an isolation room in the facility’s booking area at the time of his death. These cells are inappropriate for inmates in mental health crisis because it is impossible to provide sufficient supervision of such inmates. The cells have solid doors with small windows. There are no panic buttons or intercoms and no video surveillance in any of the cells. Furthermore, the padded room was not designed to deter inmate suicide. As noted above, an inmate was able to pull large chunks of foam from the padded wall, and an exposed sprinkler head provided a hanging opportunity.
The medical area, with its current staffing, is equally insufficient. An inmate placed on watch status in a medical unit cell for his own safety due to mental illness and seizure disorder was able to cut both of his wrists with a razor blade within 5 minutes of his arrival in that cell. The only way that staff knew that the event had occurred was when blood began running down the floor from his cell. This example also illustrates that staff lacked the skills to search the inmate adequately and make appropriate decisions about what he should have in his possession prior to placing him in that cell.
Some suicide attempts by cutting occurred in the housing units. Staff learned of these incidents only through inmates reporting the emergencies on the intercom. At the time of our visit, several of the intercoms from the housing units to staff in the control room were broken. If inmates are unable to get the attention of staff quickly in an emergency, the response of

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rescue personnel could be delayed.
Staff have not been provided with the training or resources to respond properly to suicide attempts. In the booking area, where newly arrived inmates are housed, there was no tool to cut down a hanging inmate, despite the fact that the completed suicide had occurred in this area. In addition, only 27 staff members had received training in CPR and First Aid at the time of our visit. As the likely first responders to suicide attempts
and other health crises, all staff should be trained and provided with appropriate equipment to respond to such emergencies while awaiting medical staff.
Our review also indicates that inmates on suicide watch are not consistently seen by the mental health provider in a timely manner and are sometimes released from suicide watch without any evaluation or mental health clearance. For example, one inmate reported that he had cut himself. Staff placed him in the Health Services Unit for treatment of his lacerations and kept him there on suicide watch. He stayed in the Health Services Unit, on suicide watch, for nine days without once being seen by the mental health provider. On the tenth day, he was released back to administrative segregation, still without having seen a mental health provider or receiving mental health clearance to return to administrative segregation. The failure to respond to this inmate’s mental health crisis, and the subsequent release of this inmate from suicide watch without a mental health evaluation, placed the inmate at risk for continued crisis and/or another suicide attempt.
Another incident involved an inmate who cut her wrists with a razor and was placed on a 15-minute suicide watch in the medical unit. According to the subsequent investigation of the incident, the inmate was upset because her medications were stopped. Although she had been seeing the mental health provider every two weeks for counseling, the counselor’s records contained no notes or information concerning her attempted suicide. The inmate was treated for lacerations to her wrists and released from suicide watch without ever receiving a mental health evaluation or mental health clearance. Absent appropriate evaluation and intervention, this inmate remained a risk to herself.
The Detention Center has the ability to refuse admission to inmates who present at booking in a severe mental health crisis,

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and also has a protocol for referring inmates with emergent mental health needs to the local hospital for appropriate care when the inmate’s needs exceed the facility’s capabilities. Our review indicates that the Detention Center underutilizes these options and fails to refer inmates to outside care when necessary.
Completed suicides and incidents of attempted suicide should be thoroughly reviewed to identify gaps and inadequacies in the provision of care. Information gained through morbidity and mortality reviews plays a critical role in preventing future incidents. PNA’s policy is to initiate a mortality review
following the death of an inmate. However, our review of the mortality review PNA conducted following the suicide of the inmate described above, revealed that PNA failed to assess critically the care and treatment of this inmate prior to his death. The mortality review provided a chronological history of the events leading up to his death but lacked a self-critical analysis of treatment failures.
D. PROTECTION FROM HARM
1. Booking Area
The booking area includes a small group of cells that are used to house inmates who have arrived recently, as well as some inmates on administrative or punitive segregation, some experiencing mental health or medical problems, or in protective custody. In this area there are 14 cells, one of which is padded and has no plumbing. Four of the larger cells (“the holding cells”) are used to house inmates until staff screen and place them in the general population. Except for one of the cells designed for disabled inmates, none of the holding cells has beds or other furnishings other than the toilet and sink and some narrow movable benches.
The booking cells, and especially the holding cells, are hot, stuffy, have poor circulation, have a foul smell and are unsanitary. The holding cells at times have too many inmates to allow for their safety and health, particularly since inmates are kept in these cells for up to five days before they are placed in the general population. We saw some cells with inmates lying on mattresses on the floor from wall to wall, and occupying all available space on benches. Two of the holding cells and one of the smaller cells had no light at all, neither natural nor

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artificial. Each cell has a narrow window that provides minimal light from the hallway. It was difficult to observe the inmates in those cells, creating an unsafe condition in which inmates could be victimized without staff being able to see anything through the doors. Because there is insufficient staff assigned to this area, staff cannot open doors frequently enough for proper surveillance, to compensate for the poor visibility through the windows. As an illustration of the difficulty staff have properly supervising these cells, on one occasion inmates got into a dispute which inmates were smoking in the cell, which is prohibited. The inmates eventually set off the sprinkler. The smoking, the dispute and the sprinkler tampering all occurred before an officer noticed and intervened.
Conditions in these cells lend themselves to inmate unrest. In one incident, two inmates were forcing others to move from where they were sleeping to give them the preferred spaces. An altercation broke out, and an inmate who refused to move from his spot sustained injuries. Furthermore, mixing sometimes agitated, intoxicated inmates with the rest of the newly arrived inmates is a recipe for conflict in these poorly ventilated, tight quarters, and sometimes leads to violence.
In another troubling incident, an older female inmate with a history of victimization was housed in a segregation cell in the booking area with another female inmate. Both women report that one of the male porters (an inmate with cleaning duties) repeatedly harassed her, making sexually explicit comments, threatening to find her in the shower and assault her. At one point he showed his exposed penis to her through the window of her cell. Several days after the incident, when we interviewed this woman, she was still traumatized by the experience. She reported that following these incidents she refused to shower during her five days in segregation because she believed that officers would not protect her.
In fact, there is insufficient staffing in the booking area to keep inmates safe. Only one officer is assigned to do rounds of the cells, admit and release inmates from the area, respond to other inmate needs and take inmates out for showers. The shower areas are around the corner, so an officer cannot provide supervision both in the showers and cells at the same time. Inmate porters move about the area without supervision. Use of this area for medical, protective, disciplinary and

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administrative segregation is inappropriate. The area is busy with incoming and outgoing inmates, which leaves staff unable to respond to the needs of inmates on special status. As described above in the suicide prevention section (C), the staffing is so thin that an inmate in this area was able to complete a suicide in one of the booking cells before staff noticed.
The jail appears to have trouble processing inmates into general population with appropriate speed. One woman returned to the facility after a medical furlough for shoulder surgery. Despite her discomfort she was kept for three days in the holding cells without a bed or appropriate follow-up medical attention before being allowed back into general population.
Furthermore, the jail is responsible for detaining a number of offenders brought in under the New Mexico Detoxification Act following disorderly behavior, for the purpose of “protective custody” to detoxify from alcohol or drugs.1/ The jail does not process these inmates into the general population, but rather leaves them in the booking area. Despite the high frequency with which inmates who have abused alcohol or drugs are received in the booking area, the staff in that area were unaware of signs and symptoms of withdrawal. Officers are insufficiently trained in the detection and handling of intoxicated inmates. This puts inmates at risk that serious and sometimes life-threatening withdrawal symptoms may not receive prompt response.
2. Sexual Misconduct and Privacy Concerns
As part of our investigation, we reviewed the circumstances for women housed at the Detention Center. Our review revealed serious concerns regarding past sexual misconduct under the previous management and insufficient prevention efforts under the new management. Staff provided anecdotal evidence of sexual relationships between staff and inmates under the previous management, as well as at least one incident in which male inmates were allowed into the female housing areas for several hours. Under the new management, one inmate became pregnant, although investigation did not reveal whether the father was an inmate or staff. The reporting and investigative system at the jail is flawed, which may have contributed to a lack of information available regarding this and other occurrences at the facility. While we did not determine that there is an ongoing
1/See New Mexico Statutes Annotated 1978, §§43-2-2 through 
 43-2-22.


- 25 -
pattern or practice of sexual misconduct that violates the constitution under the new management, we do recommend that the new management make more concerted efforts to guide and train staff, avoid leaving female inmates isolated and vulnerable, and improve the system of reporting, investigation and accountability. We have provided technical assistance aimed at addressing our concerns. In addition, we also have provided technical assistance regarding ways to address the lack of privacy for women inmates during times when they are housed in the medical unit and are undressed.
E. LIFE SAFETY AND SANITATION
1. Fire Safety
Inadequate fire safety measures at the Detention Center compromise residents’ safety. The facility does have sprinkler and alarm systems, self-contained breathing apparatus for staff
to use in an emergency, and up-to-date fire extinguishers throughout the building. However, systems for fire drills, emergency evacuation and fire prevention are inadequate.
Absence of a reliable fire drill program risks harm to inmates. During our on-site visit, we asked the facility to conduct a fire drill. Administrative staff determined which unit to drill and which staff to use. Even under these controlled circumstances, security staff only evacuated one of the six sections of the housing unit. Staff were reluctant to evacuate the entire unit because they did not believe that they had safe evacuation routes and holding areas to do so. This demonstrates that facility staff do not have faith in their emergency evacuation procedures and are unprepared for evacuation should the need arise. Furthermore, most staff we questioned, many of whom had been working at the facility for seven months or longer, had never participated in a fire drill.
During a test of emergency keys, the Key Control Manager had a difficult time identifying keys needed to exit the facility. Keys were grouped with as many as 16 on a ring, and it was necessary to cross match them against numbers on a clipboard to find the right key for every door. In the case of a fire or other evacuation emergency, such a system would be too slow and cumbersome to evacuate inmates and staff safely. In addition, the facility’s fire plan has not been approved by the State Fire Marshal, and the facility is not conducting fire safety

- 26 -
inspection rounds.
2. Food Service
The food service operation at The Detention Center does not meet sanitation requirements and puts residents at risk of developing food borne illness. We encountered food service and preparation equipment that was not properly cleaned. Some foods were stored in unsanitary containers or locations. In addition, several practices suggest a lack of sufficient concern for maintaining food at safe temperatures. We encountered bulk foods that required refrigeration sitting in a hallway next to a dry storage area following a delivery, with no staff attempting to refrigerate them. Furthermore, one of the facility’s refrigerators had been showing temperatures well above an acceptable safe temperature for some time without being repaired. In addition, foods, once prepared, were not maintained at safe temperatures until service.
Food service workers were not screened properly for health problems before being permitted to prepare food. Only half of the food service workers had been cleared by Health Services staff to ensure they were healthy enough to work in the kitchen. Furthermore, the supervisor was conducting daily visual health checks of workers only after they had begun working with food for the day, and without asking them any questions about their health. We noticed an inmate with visible open wounds on his wrists slicing watermelon with bare hands, instead of plastic gloves. The supervisor had not noticed this condition, determined whether the inmate should be working, or provided close enough supervision to ensure that he was using proper protective practices.
3. Clothing and Mattresses
Laundry at the Detention Center is conducted with insufficient frequency to maintain proper hygiene. In addition, insufficient underwear is provided to inmates. We encountered inmates who had been at the facility for two or three weeks without being given a pair of underwear. Some had one pair of their own, and others were forced to wear the uniforms without underwear. Furthermore, the facility launders inmates’ clothing with insufficient frequency for adequate personal hygiene.
Many of the facility’s mattresses were old and cracked, and some were torn, exposing the inner stuffing. Mattresses in this

- 27 
-
condition cannot be properly sanitized. By the time of our second visit, the facility had purchased 200 new mattresses, which should at least partially address the problem.
In the booking area, where inmates sometimes stay for up to five nights in rooms without beds with up to 17 people (see above, Section D(1)), we encountered some inmates who could not get sheets to use with the torn mattresses. As a result, inmates are forced to sleep directly on the mattresses, which they place either on the bare floor or on narrow benches. Some inmates staying overnight in booking had not even been provided with mattresses.
4. Infection Control, Hygiene and Public Health
The Detention Center fails to take reasonable steps to prevent the spread of airborne pathogens. For example, chart reviews revealed that it takes as long as one to three weeks for inmates with positive skin tests for tuberculosis to receive chest x-rays. The Detention Center has no respiratory protection program, and inmates with positive skin tests are not isolated, as they should be, until their chest x-rays are returned and confirmed to be negative for tuberculosis. Accordingly, inmates and staff are at risk for exposure and transmission of tuberculosis.

The Detention Center also fails to take reasonable steps to prevent the spread of blood borne pathogens. Staff and inmate workers are not consistently trained in universal precautions, and the Detention Center has no plan or training for how staff should handle high risk exposures to blood, such as needle stick injuries. One hazardous waste container we observed was not lined with a red plastic biohazard bag, and the container was half-filled with loose trash.

Staff at the Detention Center also fail to adhere to appropriate hygiene standards. For example, we found urine stored in a container in a medication refrigerator. In addition, several of the areas in which medical staff would be expected to wash their hands regularly lacked the proper plumbing fixtures or supplies to do so. Inmates reported having trouble getting toilet paper when they needed it.

F.

ACCESS TO COURTS AND OPPORTUNITY TO REDRESS GRIEVANCES

- 28 -
The County has a responsibility to provide its inmates with reasonable access to the courts to challenge their sentences, directly or collaterally, and the conditions of their confinement. The County is not providing inmates the tools needed for such access through a law library, legal assistance, forms system or otherwise.
The grievance system at the Detention Center is not providing a meaningful path for redress of inmate complaints. While the facility has a grievance coordinator who processes grievances, the facility fails to document its actions in response to inmates’ complaints and fails to let the inmate know how it has responded. The management frequently rejects inmate grievances that are formally incomplete, despite the fact that they include sufficient information to process them meaningfully.
Furthermore, the grievance system requires that inmates confront staff and attempt to resolve problems before filing a grievance. Given the power difference between inmates and staff, this requirement makes it even less likely that the grievance system will be a realistic avenue for reporting staff misconduct. In addition, when we were visiting the housing units, there were no grievance forms available in some units. Even after we brought this to the attention of staff, when we checked again there were still no forms available. No grievance forms were available in Spanish, despite the sizeable population at the facility that speaks and/or reads only Spanish.

III. REMEDIAL MEASURES

In order to rectify the identified deficiencies and to protect the constitutional rights of the facility’s inmates, the County should implement, at a minimum, the following measures:

A.

MEDICAL CARE

1)

Provide for a more confidential environment in which to

conduct medical and mental health booking screenings,

recognizing legitimate security concerns.

2)

Revise and implement policy, procedures and practices to

ensure that all inmates receive the initial health

screening in a timely fashion.

- 29 -

3)

Revise and implement policy, procedures and practices to

ensure that inmates reporting or exhibiting possible

signs of serious medical or mental health needs at

booking are referred promptly to the Health Services Unit

and receive appropriate follow-up care.

4)

Revise and implement policy, procedures and practices to

ensure that inmates receive a comprehensive medical

history and physical examination, performed by

appropriately trained, licensed and, if appropriate,

supervised personnel, within 14 days of their arrival at

the facility.

5)

Screen all incoming inmates for syphilis. Assess inmate

risk for other sexually transmitted diseases, such as

chlamydia and gonorrhea, and screen high risk inmates

using modern laboratory methods.

6)

Revise and implement policy, procedures and practices for

addressing drug and alcohol withdrawal to ensure that all

inmates are screened and/or treated appropriately if they

report or exhibit signs of drug or alcohol withdrawal.

7)

Develop and implement policy, procedures and practices to

ensure timely referral for evaluation and treatment of

inmates who exhibit signs and symptoms of mental illness.

8)

Develop and implement policy, procedures and practices

for validating and continuing, if appropriate, current

prescriptions for medications of incoming inmates.

9)

Ensure appropriate staffing for the Health Services Unit

by retaining intermediate and advanced practitioners who

are able to provide adequate treatment and monitoring of

inmates with serious medical needs, in a timely fashion,

without practicing beyond the scope of their licensure.

10)

Establish policy, procedures and practices for evaluating

and improving responsiveness to inmate sick call

requests.

11)

Establish a chronic care system that includes gathering

information and establishing medication upon intake into

the facility, establishing a system of care of inmates

with chronic diseases at established intervals,

standardizing the information gathered at treatment

- 30 -

visits, devoting sufficient attention to inmates whose uncontrolled conditions must be stabilized, and ensuring that inmates with chronic medications have access to those medications when appropriate.

12)

Improve morbidity and mortality review process to ensure

that deaths are thoroughly and effectively evaluated and

any problems with care or access to care that are

revealed through that process are resolved.

13)

Revise and implement policies, procedures and practices

to ensure that diabetics and other inmates who need

medically appropriate nutrition receive an appropriate

diet.

14)

Develop and implement policy, procedure and practices to

ensure that pregnant inmates receive prenatal care from

appropriately trained and experienced medical

professionals on a timely basis.

15)

Develop and implement policies, procedures and practices

to ensure that inmates whose medical needs require

specialized care are promptly scheduled for and

transported to outside care appointments.

16)

Develop and implement policies, procedures and practices

to ensure that the findings and recommendations of

outside care providers are documented in the medical

chart of each inmate referred for outside care, and that

treatment recommendations are followed once the inmate

returns to the facility.

17)

Eliminate the practice of using protocols with medication

orders except for life-threatening emergencies.

18)

Develop and implement policy, practices and procedures to

ensure that inmates are prescribed medications only after

a physical examination by the prescribing clinician.

19)

Institute a medication management program which ensures

continuity for ordered medication, and includes a

requirement that the reason for every missed dosage of

medication will be documented and a nurse will confer

with any inmate who misses three or more doses for any

reason. Revise the formulary to include at least one

- 31 -

medication for elevated blood lipids, a proton pump inhibitor, an ACE inhibitor, an SSRI antidepressant, and birth control pills, and develop and implement a simple and efficient waiver protocol for use when off-formulary medications are needed.

20)

Implement a schedule for measuring blood levels of

medication for medications which require such monitoring.

21)

Revise and implement procedures to document the reason

for every missed dosage of prescribed medication. Adhere

to stated PNA policy of conferring with any inmate who

misses three or more doses for any reason.

22)

Develop and implement a quality improvement system that

monitors and improves deficiencies in medical care and

access, including but not limited to reviewing medication

prescribing patterns and monitoring medication usage to

assure appropriateness and continuity, and physician

review and supervision of nursing.

B.

MENTAL HEALTH CARE

23)

Provide sufficient mental health professional staffing to

meet the serious mental health needs of the jail’s

population, including staff qualified and trained to

diagnosis and treat the seriously mentally ill.

24)

Develop and implement policies, procedures and practices

to ensure that every inmate receives an initial mental

health screening upon arrival at the facility and a

mental status assessment within fourteen days of arrival.

25)

Modify the comprehensive mental health evaluation to

ensure that mental health practitioners diagnose their

patients and create treatment plans.

26)

Develop and implement policies, procedures, and practices

to ensure that a mental health caseload roster is

developed and regularly updated to reflect intakes and

discharges, and that the provision of mental health

services to inmates is tracked by the facility through an

effective management information system.

- 32 
-

27)

Develop and implement policies, procedures and practices

to ensure that staff respond to sick call mental health

requests in a timely manner and provide adequate ongoing

care to inmates determined to need such care.

28)

Institute a more thorough quality improvement system that

covers all mental health professionals.

C.

SUICIDE PREVENTION

29)

Develop and implement appropriate suicide prevention

policies, procedures and practices, including but not

limited to reducing the threshold required to trigger an

immediate mental health evaluation.

30)

Develop appropriate housing for inmates on suicide watch,

and ensure that cells in the booking area are not used

for this purpose.

31)

Develop and implement policies, procedures and practices

to ensure that inmates initially placed on suicide watch

are placed on continuous watch, and that the watch is

reduced only upon the recommendation of a mental health

professional following a suicide risk assessment.

32)

Revise and implement effective policy, procedures and

practices to ensure proper supervision of suicidal

inmates, logging of supervision, and availability of cut-

down tools for hangings.

33)

Ensure that inmates have means to communicate with staff

when necessary, through working intercoms or other

effective means of communication.

34)

Train staff to understand the signs, symptoms and

appropriate responses to potentially suicidal inmates,

including when and how to seek mental health follow-up.

35)

Develop and implement policies, procedures and practices

to ensure that inmates whose level of suicidality cannot

be properly handled at the facility are promptly

transferred elsewhere for appropriate care.

36)

Revise and implement policies, procedures and practices

to ensure that high risk inmates are placed in areas that

lessen the likelihood of completed suicide, by requiring

- 33 -

that all inmates are thoroughly searched before they are placed on watch, and that admission medical/mental health orders are written in the inmate’s chart and document allowable clothing, property, utensils, and diet.

37)

Develop and implement appropriate policies, procedures

and practices to ensure that inmates on suicide watch are

monitored sufficiently by mental health professionals and

are not released from suicide watch without clearance

from a mental health professional, and that appropriate

discharge orders are written upon release, including

treatment recommendations and required follow-up care.

38)

Develop and implement policies, procedures and practices

to ensure that thorough, self-critical mortality reviews

are conducted following the suicide or attempted suicide

of an inmate, and integrate knowledge gained from such

reviews into suicide prevention protocols.

D.

PROTECTION FROM HARM

39)

Staff the booking area sufficiently to provide reasonable

safety to inmates.

40)

Cease using the booking area for inmates on segregation,

protective, medical, mental health or other special

status.

41)

Develop and implement policies, procedures and practices

to ensure the safe and proper housing of inmates

experiencing withdrawal from drugs or alcohol. Properly

train staff to identify signs and symptoms of withdrawal

and respond appropriately.

42)

House inmates in the booking area for only brief periods

of time.

E.

LIFE SAFETY AND SANITATION

43)

Develop and implement policies, procedures and practices

to ensure that staff conduct adequate fire drills for all

shifts, covering all institutional areas.

44)

Develop and implement policies, procedures and practices

- 34 -

to ensure that staff conduct adequate fire safety inspections.

45)

Revise the emergency key system to ensure that keys are

readily identifiable and available to those who need

them.

46)

Develop and implement policy, procedures and practices to

ensure that the facility’s fire safety systems are

maintained in order and operable.

47)

Develop and implement policies, procedures and practices

to ensure that food storage, preparation and service

systems are maintained in a sanitary manner.

48)

Develop and implement policies, procedures and practices

to ensure that inmates and staff who work in food service

are in proper health to do so.

49)

Provide all inmates with properly cleaned and adequate

bedding and clothing. Ensure access to needed hygiene

supplies.

50)

Develop and implement policies, procedures and practices

to ensure that the facility follows nationally accepted

standards for infection control and hygiene.

E.

ACCESS TO COURTS AND OPPORTUNITY TO REDRESS GRIEVANCES

51)

Develop and implement policies, practices and procedures

to ensure that inmates have adequate access to the

courts.

52)

Reform the grievance system so that grievances are

processed and legitimate grievances addressed and

remedied in a timely manner, responses are documented and

communicated to inmates, inmates need not confront staff

prior to filing grievances about them, inmates may file

grievances confidentially, and grievance forms are

available on all units. Ensure that grievance forms are

available in Spanish.

- 35 
-

53)

Develop and implement a quality assurance plan to address

all deficiencies identified in this letter.

****

In light of the County’s cooperation in this matter, under separate cover we will send you our experts’ reports. Although the experts’ reports and work do not necessarily reflect the official conclusions of the Department of Justice, their observations, analyses and recommendations provide further elaboration of the issues discussed above, and offer practical assistance in addressing them.

Pursuant to CRIPA, the Attorney General may institute a lawsuit to correct deficiencies of the kind identified in this letter forty-nine days after appropriate officials have been notified of them. 42 U.S.C. § 1997b(a)(1). We would prefer, however, to resolve this matter by working cooperatively with you, and we have every confidence that we will be able to do so.

Sincerely,

/s/ Ralph F. Boyd, Jr.
Ralph F. Boyd, Jr. Assistant Attorney General
cc: Steven Kopelman, Esq. Santa Fe County Attorney
Mr. Cody Graham 
 Warden
 Santa Fe County Correctional Facility

David C. Iglesias, Esq.
 United States Attorney
 District of New Mexico

Mr. Robert Ecoffey
 Director
 Office of Law Enforcement
 Bureau of Indian Affairs 

Mr. William McClure

- 36 -
Detention Specialist
 Office of Law Enforcement
 Bureau of Indian Affairs

William Myers, Esq.
 Solicitor
 United States Department of the Interior

Ms. Edith Blackwell
 Acting Associate Solicitor
 Division of Indian Affairs
 United States Department of the Interior

Ms. Kathleen Hawk Sawyer
 Director
 United States Bureau of Prisons

Mr. Michael B. Cooksey
 Assistant Director 
 Correctional Programs Division
 United States Bureau of Prisons

Ms. Loren Grayer
 Senior Deputy Assistant Director
 Community Corrections & Detention

Chris Erlewine, Esq.
 General Counsel
 Office of the General Counsel
 United States Bureau of Prisons

Mr. Benigno G. Reyna
 Director
 United States Marshals Service

Ms. Lydia Blakey
 Acting Assistant Director 
 Prisoner Services Division
 United States Marshals Service

Gerald Auerbach, Esq.
 Acting General Counsel
 Office of the General Counsel
 United States Marshals Service


 
 MEMORANDUM OF AGREEMENT BETWEEN THE UNITED STATES AND SANTA FE COUNTY

TABLE OF CONTENTS

I.

DEFINITIONS

II. INTRODUCTION

III. MEDICAL AND MENTAL HEALTH CARE

A Standard

B. Medical and Mental Health Staffing and Professional Credentials C. Intake Medical and Mental Health Screening, Referral, and Assessment D. Access to Medical and Mental Health Services

E. Emergency Care

F. Continuity of Care and Access to Outside Providers

G. Chronic Diseases

H. Treatment of Female Inmates

I.

Drug and Alcohol Withdrawal and Detoxification

J.

Medication Management

K. Mortality Reviews

L. Supervision in the Medical Unit

M. Infection Control

IV. SUICIDE PREVENTION

V. SECURITY AND SAFETY

A. Inmate Supervision B. Grievances and Investigations C. Booking Area D. Inmate Classification E. Information Regarding Access to Constitutionally Required Services
VI. QUALITY MANAGEMENT

VII. STAFF TRAINING AND SUPERVISION

VIII. DOJ MONITORING OF AGREEMENT, TIME FRAME FOR SUBSTANTIAL COMPLIANCE, AND TERMINATION OF THE AGREEMENT

I. DEFINITIONS For the purposes of this Memorandum of Agreement ("Agreement"), A. "Clinical staff' means medical staff, nursing staff, and Emergency Medical Technicians
("EMTs") employed at the Santa Fe County Adult Detention Center ("the Detention Center"). B. "The County" means Santa Fe County and its elected officials, employees, agents, and
Santa Fe County contractors responsible for the operation of and provision of services at the Detention Center.
C. "Health services staff' means any and all healthcare staff, who by virtue oflicense, credentials and/or training, provide health services at the Detention Center.
D. "Inmates" shall mean individuals detained at, incarcerated in, in the custody of, or confined at the Detention Center.
E. "Inmates with chronic disease" shall include, but are not limited to, those inmates who have been diagnosed with diabetes, hypertension, asthma, cardiac disease, Human Immunodeficiency Virus ("HIV") infection, viral hepatitis, and seizure disorder, and may include irunates with other chronic diseases.
F. "Medical staff' means licensed physicians, licensed physician's assistants, and licensed nurse practitioners employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those health services she or he has undertaken to provide.
G. "Mental health professional" means an individual employed at the Detention Center currently licensed to the extent required by the State of New Mexico to deliver those mental health services she or he has undertaken to provide.
2

H. "Nursing staff' means licensed registered nurses ("RNs") and licensed practical nurses ("LPNs") employed at the Detention Center employed at the Detention Center currently licensed to the extent required by the State ofNew Mexico to deliver those health services they have undertaken to provide. It does not include nurse's aides, certified nursing assistants, or EMTs.
I. "The parties" means the County and the United States. 1. "The Detention Center" means the Santa Fe County Adult Detention Center, an adult detention facility, sometimes called the Santa Fe County Correctional Facility, which is currently located at 4312 New Mexico Highway 14, Santa Fe, New Mexico, as well as any facility that is
built to replace or supplement it. "The Detention Center" does not include alternatives to
incarceration such as off-site drug and alcohol treatment centers, detoxification centers, outside mental health treatment facilities, or work release centers.
K. "Train," when the term is used in remedial provisions of this Agreement, means adequately instruct in the skills addressed, including assessment of mastery of instructional material.
II. INTRODUCTION
1. On March 20, 2002, the United States, through the Department of Justice ("DOl"), notified the then-Chairman of the Santa Fe County Commission, Paul Duran, of DOl's intent to investigate conditions of confinement at the Detention Center, pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997, to determine whether those conditions violated irunates' constitutional rights.
2. In May 2002, the United States toured the Detention Center.
3

3. On March 6, 2003, the United States notified the County of its findings that certain conditions at the Detention Center violated inmates' constitutional rights and subjected them to harm: that the County was deliberately indifferent to inmates' serious medical and mental health needs; that persons confined at the Detention Center suffered harm or the risk of harm from deficiencies in the Detention Center's suicide prevention, fire safety and sanitation systems; and that the County failed to protect some inmates from hann and fails to provide inmates sufficient access to the courts and opportunity to seek redress of grievances.
4. The County denies the allegations set forth in the DOl's findings letter of March 6, 2003. In particular, the County asserts that conditions at the Detention Center have never violated state or federal law or the constitutional rights of inmates. The County nonetheless cooperated throughout the course of the DOJ investigation and demonstrated a willingness to undertake measures to improve conditions at the Detention Center.
5. Nothing contained in this Agreement constitutes an admission that the County has ever violated the constitutional rights of any inmates, nor is it an admission that any prior or present policy, procedure, practice, event, circumstance, act or failure to act by the County, its elected officials, contractors, agents or employees violated the civil rights laws of the United States, failed to meet applicable federal or constitutional standards, or otherwise fell short of any standard of care imposed by law.
6. The parties enter into this Agreement for the purpose of avoiding the risks and burdens of litigation and in order to describe conditions both parties wish to see maintained at the Detention Center.
4

7. This Agreement is not intended to serve as an interpretation of law or to establish constitutional standards of care. The County is determined to provide cost effective custodial services, including medical care, to its irunates and to identify opportunities to improve the quality of that care beyond the strict constitutional minimum.
8. For a number of years, the Detention Center has been managed and operated by private corporations pursuant to contracts with the County. Since October 2001, Management and Training Corporation ("MTC") has managed the Detention Center. Irunates at the Detention Center also receive services provided by independent contractors other than MTC. MTC provides medical care and mental health services to inmates at the Detention Center pursuant to a subcontract. From October I, 2001 through September 30, 2004, the provider with the subcontract to provide medical and mental health services was Physician's Network Associates ("PNA"). The provider with the subcontract to provide medical and mental health services from October 1, 2004 through September 30, 2005 is Correct Care Solutions.
9. Written agreements (between the County and MTC, and between MTC and its subcontractors) set forth the terms and conditions of the respective contractual relationships described in the preceding paragraph. The County is responsible for ensuring that future contracts with MTC or its successor, as well as any subcontracts entered during the term of this Agreement, both acknowledge the binding effect of this Agreement, and obligate the contracting party to implement its provisions. Notwithstanding the foregoing, nothing in this Agreement or in any contract hereafter executed by the County with any manager or operator of the facility, shall abrogate the County's responsibility to ensure compliance with this Agreement.
5

10. The parties acknowledge that the County already has policies that address areas described in this Agreement. The County will revise and/or develop as necessary its current policies, procedures, protocols, training materials and practices to ensure that they are consistent with, incorporate, address, and implement all provisions of this Agreement. The County shall revise and/or develop as necessary other written documents such as screening tools, logs, handbooks, manuals and forms, to effectuate the provisions of this Agreement.
11. The parties to this Agreement do not intend to create in any non-party the status of third party beneficiary. This Agreement shall not be construed so as to create a private right of action to any non-party against the County or the United States. The rights, duties and obligations contained in this Agreement shall only bind the parties to this Agreement. III. MEDICAL AND MENTAL HEALTH CARE
A. Standard 12. Serious Medical and Mental Health Needs The County shall provide adequate services to address the serious medical and mental health needs of all imnates. B. Medical and Mental Health Staffing and Professional Credentials 13. Medical Director The medical director of the Detention Center shall be a qualified, licensed physician, shall supervise all clinical practices and medical policy development at the facility, and shall communicate problems and resource needs to the Warden. The medical director of the Detention Center shall have ultimate responsibility for supervising clinical decision-making. 14. Psychiatrist Staffing The County shall retain a psychiatrist for a sufficient number of hours per week to see patients, prescribe psychotropic medications, develop individualized treatment plans for inmates with serious mental health needs, supervise care provided by other
6

mental health practitioners at the facility, review charts, review the results of diagnostic and laboratory tests, and review policies, procedures, and protocols. The psychiatrist shall take a lead role in mental health services management as well as clinical treatment, shall communicate problems and resource needs to the Warden, and shall serve as the ultimate clinical authority at the facility for mental health care.
15. Physician Staffing Physician staffing shall be sufficient to provide adequate care for patients, review policies, procedures and protocols, supervise care provided by lower level practitioners including chart review, and participate in quality improvement and infection control programs.
16. Health Services Staffing Health services staffing levels shall be sufficient to provide adequate treatment for inmates' serious medical and mental health needs by qualified and trained health services and mental health professionals. Appendix A sets forth the required staffing minima for registered nurses, psychiatrist, physician, and other medical and mental health staff.
17. Scope of Practice All persons providing medical or mental health care shall meet applicable state licensure and/or certification requirements. Health services staff shall not practice outside the scope of their licensure and training.
18. Health Services Staff Training The County shall train medical and mental health staff sufficiently to perform their duties at the Detention Center in accordance with this Agreement. This training shall include guidance to ensure that staff do not practice outside the scope of their licensure, and that they refer inmates with serious medical and mental health needs for care by those qualified to treat such needs.
7

19. Correctional Officer Identification of and Response to Urgent Medical and Mental Health Needs The County shall develop and implement policies and procedures for correctional officers to refer inmates who exhibit signs and symptoms of urgent medical or mental health need including intoxication and withdrawal for appropriate medical or mental health attention. The County shall make best efforts to train all correctional officers who work with inrnates to provide first aid-responder assistance in an emergency situation (CPR, valve resuscitation and how to address serious bleeding). The County shall ensure that trained staff are available to respond in a timely fashion to any medical emergency at the facility. The County shall provide all personnel who have inmate contact with the necessary protective gear (including rubber gloves and protective mouth shields) to provide first line emergency response. The County shall train all correctional officers who work with inmates to understand and identify signs and symptoms of drug and alcohol withdrawal and other urgent medical and mental health needs.
C. Intake Medical and Mental Health Screening, Referral and Assessment 20. Privacy The County shall provide for an inmate's reasonable privacy in medical and mental health care, and maintain confidentiality of inmates' medical and mental health status, subject to legitimate security concerns and emergency situations. 21. Correctional Officer Booking Screening The County shall provide for trained correctional officers to ask inmates in a reasonably private setting at the time of booking questions covering important medical and mental health topics that may indicate need for immediate or prioritized care. Appendix B contains a list of topics to be covered during screening. Inmates who screen positively for any of these items shall be referred for immediate or prioritized screening by the intake nurse or other health care staff as appropriate. Correctional officers
8

supervising newly arrived inmates shall physically observe the conduct and appearance of these inmates to detennine whether they have a more immediate need for medical or mental health attention prior to their initial health screenings by clinical staff.
22. Initial Clinical Health Screening The County shall provide for initial clinical health screening by clinical staff for new inmates and inmates transferring from other correctional institutions within forty eight (48) hours of each inmate's arrival at the facility. The County shall ensure that staff performing initial health screenings are trained to complete the assessments. For this initial health screening, clinical staff shall record and seek the inmates' cooperation to provide: (I) medical, surgical, and mental health history, including current or recent medications; (2) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use; (3) history of substance abuse and treatment; (4) pregnancy; (5) history and symptoms of communicable disease; (6) suicide risk history; and (7) history of mental health treatment, including medication and hospitalization. Staff shall attempt to elicit the amount, frequency and time of the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. This initial health screening information shall promptly become part of an inmate's medical record.
23. Unified Medical Record Staff shall retrieve all retrievable medical and mental health records from an inmate's previous period of incarceration at the Detention Center (where the record can be positively matched to the inmate) prior to the inmate's next medical or mental health encounter after the clinical health screening, and shall consolidate them with the inmate's current medical record. The County shall maintain unified medical, dental and mental health records. All records shall be timely filed in patients' medical charts. For purposes of this agreement, "timely
9

filed" means within ten (1 0) days of receipt, review, creation, or use, except for Medication Administration Records, which shall be filed within ten (I 0) days of the end of a month. Laboratory reports shall be timely reviewed by the appropriate health services staff, filed within three (3) days of receipt, and noteworthy results reported to inmates as medically appropriate.
24. Outside Medical Records For inmates with chronic diseases, pregnancy or mental illnesses, if a member of the medical staff or a mental health professional requests retrieval of outside medical records, the County shall request a release of information from the inmate and if granted, shall send a request for the inmate's treatment records to current treatment providers identified by the illlllate within two days.
25. Tuberculosis f''TB") Testing As part of the fourteen day health assessment, the County shall routinely perform on all inmates a tuberculin skin test (i.e. Mantoux "PPD"), unless such test is wmecessary (i.e. history of prior positive tests) or medically contra-indicated according to Centers for Disease Control ("CDC") Guidelines. The County shall read the PPD forty-eight (48) to seventy-two (72) hours after placement of the PPD. Within 72 hours of determining that an inmate's PPD test is positive, the County shall schedule an appointment for a chest x-ray of the inmate. The County shall ensure that inmates arc transported to the scheduled appointment. The County shall follow CDC guidelines, in effect on the date this Agreement is executed, for management of inmates with TB infection, including providing prophylactic medication when medically appropriate. The County will consider implementing subsequently revised CDC guidelines. Inmates who exhibit symptoms of contagious TB shall be housed in the health services unit until they may be transferred to another facility or location where respiratory isolation is
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available. The facility shall provide for infection control and for the safe housing and transportation of such inmates.
26. Screening. Testing and Treatment of Communicable Diseases The County shall develop and implement a policy for STD screening, testing, and treatment that is consistent with community standards and appropriate to the inmate population of the Detention Center. The policy shall be implemented within 120 days of the date this Agreement is executed.
27. Refusal to Participate In the event an inmate refuses to cooperate voluntarily in the screening, records retrieval and/or test(s) referred to in paragraphs 22, 24, 25, and/or 26, after the inmate is advised of the importance to the inmate's health needs, the inmate will be asked to sign a refusal form, which shall be maintained in the inmate's health record. If the inmate refuses to sign, such refusal shall be documented by Health Services Unit personneL If the inmate is exhibiting symptoms of contagious disease, the County shall take steps medically appropriate to maintain the safety of other inmates and staff.
28. Continuity of Medication at Intake The County shall implement a medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a timely manner, as medically appropriate when medically necessary. Within twenty-four hours of an inmate's arrival at the facility, or sooner if medically necessary, the County shall decide whether to continue the same or comparable medication for serious medical needs as an inmate reports on arrival that she or he has been prescribed. lfthe inmate's reported medication is discontinued or changed by medical staff, medical staff shall evaluate the inmate face-to-face as soon as medically appropriate. The County shall develop and implement a protocol and screening
II

tool to guide health services staff in gathering necessary information and present such information to medical staff for medication continuity decisions.
29. Expedited Referral for Medical and Mental Health Needs When the initial clinical health screening indicates that an inmate has acute health or mental health needs the County shall provide timely care by trained and licensed medical staff, registered nurses, or mental health professionals as soon as medically necessary, but no later than twenty-tOur (24) hours after the initial health screening. The County shall schedule individuals with chronic health or mental health needs and those who are pregnant but who present in a stable condition to be seen by medical staff or mental health professionals as soon as medically necessary. Incoming inmates who present with current risk of suicide or other acute mental health needs will be immediately referred for a mental health evaluation by a mental health professional. Staff will observe such inmates until they are seen by mental health professionals. Incoming inmates reporting these conditions will be housed under appropriate conditions in the Health Services Unit unless and until a mental health care professional clears them for housing in segregation or with the general population.
30. Fourteen Day Health Assessment The County shall perform full physical and mental health assessments for each inmate within fourteen (14) days of an inmate's arrival at the Detention Center, unless the County knows that an inmate will be incarcerated for fewer than thirty (30) days. For inmates incarcerated for fewer than 30 days, the County shall conduct the testing required by paragraph 25. The assessment shall include a comprehensive medical history, physical examination, mental health history, and current mental health status examination. Qualified health services staff may gather health history and vital signs from an inmate. The physical examination
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shall be conducted by medical staff or registered nurses. Records documenting the assessment and results shall become part of each inmate's medical record. A re-admitted inmate or an inmate transferred from another facility who has received a documented full health assessment within the previous three months and whose receiving screening shows no change in the inmate's health status need not receive a new full physical health assessment. For such inmates, qualified personnel shall review prior records and update tests and examinations as needed.
31. Comprehensive Mental Health Evaluation The County shall ensure that inmates identified in the intake mental health screening process, a mental health assessment, or otherwise referred for mental health services receive a comprehensive mental health evaluation from a mental health professional licensed and trained to diagnose, within twenty four (24) hours of referral for an expedited comprehensive evaluation, or seventy-two (72) hours of referral for a routine comprehensive evaluation. The comprehensive mental health evaluation shall include a recorded diagnosis section, including a standard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If mental health staff find a serious mental illness, they shall treat appropriately. The County shall review available information regarding any diagnoses made by the inmate's community or hospital treatment provider.
D. Access to Medical and Mental Health Services 32. Access to Medical and Mental Health Services Initial paper screening of medical and mental health care request slips shall be conducted within twenty-four (24) hours of health services staff's receipt and may be conducted by an LPN or EMT. All inmates who submit medical care request slips indicating the need for clinical judgment and/or physical assessment
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shall be seen by medical staff or registered nurses as soon as medically necessary. Registered nurses performing acute care shall be guided by physician approved nursing protocols that are updated annually, and shall consult with or refer patients to the on-call medical staff as appropriate. Medical care requests that do not indicate the need for clinical judgment and/or physical assessment may be handled by LPNs. The County shall develop and implement a protocol guiding the distinction between those medical care request slips that require face-to-face services and those that do not. Written requests for mental health services shall be forwarded to a mental health professional and timely evaluated by him or her. Notwithstanding the foregoing, the health services worker fonvarding sick call slips to mental health providers shall respond to any apparently emergent need in accord with paragraphs 36 and 38.
33. Acute care policies. procedures and practices The County shall ensure that its acute care policies, procedures, and practices address and guide the following: (1) written medical and mental health care request slips available in English and Spanish; (2) a confidential collection method in which the request slips are collected by health services staff seven days per week; (3) a Jogging procedure to record the date and summary of each request for acute care, the date the inmate was seen and the name of the person who saw him or her, the disposition of the medical or mental health visit (e.g., referral; whether inmate scheduled for acute care visit), and if follow up care is necessary, the date and time of the inmate's next appointment; (4) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; (5) opportunity for all inmates, irrespective of primary language, to access medical and mental health care; and (6) recording of results of the medical or mental health care request in the inmate's medical record.
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34. Rounds Mental health professionals shall make monthly rounds in the housing units to identify inmates who may have mental health needs but who have not accessed mental health services through the sick call system.
35. Segregation Appropriately trained clinical staff shall conduct documented rounds in disciplinary, administrative, and protective custody segregation areas of the facility at least two times per week, and mental health professionals shall conduct documented rounds at least once per week, in order to address the serious medical and mental health needs of segregated inmates. Inmates submitting sick call requests in segregation may also access the sick call system in accordance with the system developed and implemented pursuant to paragraph 33. The County shall ensure that inmates in segregation have adequate opportunities to contact and discuss health and mental health concerns with clinical staff and mental health professionals in a setting that affords as much privacy as security will allow. The County shall ensure that clinical staff who conduct rounds in segregation are trained to identify the need for mental health services and make appropriate referrals.
36. Expedited Referral The County shall ensure that inmates requesting mental health services, inmates who become suicidal, inmates who are referred for mental health services by correctional officers, and inmates who develop serious mental illness while incarcerated, are evaluated and treated timely, irrespective of the manner in which the services are requested. Mental health professionals shall be provided with up-to-date housing lists of inmates to ensure continuity of care.
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E. Emergency Care 37. Response to Emergencies The County shall train correctional officers to recognize and respond to medical and mental health emergencies and shall ensure that inmates with emergency medical or mental health needs receive timely and appropriate care within the facility, and are promptly referred and transported for outside care when the facility is unable to provide appropriate care. F. Continuity of Care and Access to Outside Providers 38. Recovering Inmates and Inmates Unable to Care for Themselves The County shall ensure that inmates who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. All inmates rctuming to the facility after surgery or hospital treatment and inmates who cannot care for themselves shall be seen immediately by medical staff and placed or treated as medically appropriate upon return to the facility. 39. Access to Specialty Care The County shall ensure that inmates whose serious medical or mental health needs go beyond the services available at the Detention Center shall receive timely referral to appropriate medical or mental health care professionals qualified to meet their needs. The County shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialty care provider are scheduled for timely outside care appointments and transported to their appointments. Inmates awaiting outside care shall be seen by medical staff as medically necessary to evaluate the current urgency of the problem and respond as medically appropriate. The County shall seek to obtain records of care and diagnostic tests received during outside appointments in a timely fashion and include such records in the inmate's medical record or document the inmate's refusal to cooperate and release medical records.
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Following a visit to an outside specialist, medical staff, mental health staff, or a dentist shall review information and documentation available from the visit and provide reasonable follow-up care.
40. Record Keeping The County shall maintain a current log of all inmates who have been referred for outside specialty care, including the date of the referral, the date the appointment was scheduled, the date the appointment occurred and the reason for any missed or delayed appointments, and information on follow up care, including the dates of any future appointments.
41. Mental Health Services Log The County shall maintain an updated log of inmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive medication. The log shall include each inmate's name, diagnosis or complaint, and next scheduled appointment.
G. Chronic Diseases 42. Clinical Guidelines The County shall develop or adopt existing written updated clinical guidelines for chronic diseases, consistent with nationally accepted guidelines, and implement such guidelines to provide appropriate diagnosis, monitoring, treatment and continuity of care. 43. Chronic Disease Log The County shall maintain an updated log of inmates with chronic illness. The County shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmate's individual medical record. H. Treatment of Female Inmates 44. Treatment Guidelines The County shall develop and implement written guidelines for medical care specifically for women, including screening for pregnancy, and gynecological and
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obstetric care. The County shall implement timely and appropriate care for pregnant women as medically indicated, including discharge planning. The County will work with and refer pregnant inmates to community providers capable of developing individual treatment plans and assisting with discharge planning. In such cases, the County shall facilitate treatment plalllling and implement those responsibilities assigned to the County under the plan subject to reasonable security considerations.
I. Drug and Alcohol Withdrawal and Detoxification 45. Drug and Alcohol Withdrawal Identification and Treatment The County shall ensure that all irunates demonstrating symptoms of drug and alcohol withdrawal are timely identified. The County shall provide appropriate treatment, housing and medical supervision for drug and alcohol withdrawal. J. Medication Management 46. Access to Appropriate Medication The County shall ensure that inn1ates have timely access to necessary medications for known serious medical or mental health conditions. The County shall develop and implement a plan to ensure that off-formulary medications may be requested, approved, received, and administered within a reasonable period after determination by medical staff that such medication is medically necessary to treat a serious medical or mental health condition. The plan shall include a provision for expedited access to and administration of off-formulary medications when medically necessary. During the term of this Agreement, the County shall log all requests for approval of off-formulary medications, the dates of the request and approval or denial, the reasons for any denial, and the date the irunate began receiving the medication.
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47. Delivery and Continuity The County shall ensure continuity of medication by ensuring regular and timely distribution and documentation of medication to all inmates, including: access to medication in emergencies and on weekends; contemporaneous documentation and monitoring of dosages dispensed and received and documentation of refusals and no-shows; timely recording of medication records in patients' individual files; and recording and monitoring of medication errors. The County shall track refusals of medication and no-shows to be reviewed in its quality assurance program, and shall take appropriate corrective measures if the review evidences problems in medication distribution.
48. Prescribing Practices Only qualified medical staff shall prescribe medications. The only exceptions shall be following written protocols for immunizations or life-threatening emergencies. Except for renewals, inmate patients shall have a face-to-face evaluation by the prescribing clinician within seventy-two (72) hours of the telephone prescription order, for medications prescribed for serious medical or mental health illnesses or symptoms.
49. Medication Administration Records The County shall provide for complete patientspecific medication administration records for all individually administered medications. For keep-on-person medications, the County shall record delivery of the medication. The County shall document inmates' refusal to take individual dose prescription medication or receive keep-onperson medication.
50. Discharge Medication and Information When the County has advance notice of the discharge of inmates with serious medical or mental health needs from detention, the County shall provide such inmates with at least a seven (7) day supply of appropriate prescription medication, unless a different amount is medically appropriate, to serve as a bridge until inmates can arrange
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for continuity of care in the community. The County shall supply sufficient medication for the period of transit for inmates who are being transfen·ed to another correctional facility or other institution. The County shall prepare and send with transferring imnates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Detention Center. The County shall ensure that information about potential release or transfer of inmates is communicated to health services staff as soon as it is available to the County.
K. Mortality Reviews 51. Autopsy The County shall request an autopsy for every inmate who dies while in the custody of the Detention Center. 52. Mortality Reviews The County shall conduct a mortality review for each imnate death while in custody. Mortality reviews shall involve physicians, nurses, and other relevant Detention Center personnel and shall seek to determine whether there was a pattern of symptoms which might have resulted in earlier diagnosis and intervention. The mortality review shall analyze the circumstances surrounding the death. The County shall obtain any autopsy reports and related medical data or shall document the unsuccessful attempts to obtain them. The County shall address any problems with care or access to care that occurred, through training, policy revision and any other appropriate measures. L. Infection Control 53. Infection Control Plan The County shall develop and implement an infection control plan that addresses blood borne and airborne hazards and infections spread through contact. The
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plan shall include provisions for the identification, treatment, and control of Methicillin-resistant Staphylococcus Aureus ("MRSA") at the Detention Center.
54. Airborne infection The airborne infection control plan shall include comprehensive procedures for screening, diagnosis, containment and prevention, following appropriate recommendations of the Centers for Disease Control and Prevention for correctional facilities. The County shall consider any future recommendations of the Centers for Disease Control and Prevention governing the control of airborne infection in correctional facilities.
55. Training The County shall train staff and inmate workers regarding measures necessary to prevent the spread ofblood borne and airborne pathogens and infections spread through contact.
56. Hazardous waste The County shall appropriately dispose of hazardous and medical waste.
57. Toilet paper The County shall provide inmates with adequate amounts of toilet paper. 58. Laundry The County shall develop and implement a system for laundering inmates' clothing and linens in a manner that prevents spread of infection. IV. SUICIDE PREVENTION 59. Policy The County shall revise existing suicide prevention policies as necessary to include: (1) staff training; (2) identification and screening of potentially suicidal inmates; (3) appropriate housing for suicidal inmates; (4) effective watch procedures, durations and conditions of monitoring; (5) suicide intervention procedures; and (6) receipt and transmission to appropriate persons of reports of inmate suicidal behavior and information needed to protect suicidal inmates.
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60. Training The County shall train clinical, mental health and correctional officer staff who have inmate contact regarding: (1) the waming signs and symptoms of inmates at risk of suicide; (2) why correctional environments are conducive to suicidal behavior; (3) high-risk suicide periods; (4) potential predisposing factors to suicide; (5) procedure and methods for responding to inmates who exhibit such risk; (6) observation techniques; (7) searches ofirunates who are placed on suicide watch; (8) emergency procedures for responding to a suicide attempt; (9) location and use of cut-down tools and other emergency response supplies; and (l 0) how to refer inmates with mental health needs for appropriate care. All facility staff who have inmate contact shall have initial training and refresher trainings every two years.
61. Suicide Watch The County shall revise as necessary policy, procedures and practices to ensure that inmates placed on suicide watch are supervised sufficiently to maintain their safety and to address the following requirements. When staff initially place an inmate on observation, the inmate shall be strip searched and monitored until a mental health professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Such orders may include assignment of a specially trained inmate to monitor an inmate on suicide watch, as a supplement to sufficient correctional officer supervision only. On a case-by-case basis, it may be acceptable to order the housing of two suicidal inmates in the same cell. Until such assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients. Mental health staff shall provide services initially as soon as possible and then as medically appropriate to all imnates on suicide watch Monday through Friday. Mental health trained registered nurses may provide this function on weekends. On-call mental health staff shall respond as necessary to provide care to inmates newly placed on suicide watch on the weekends. Inmates
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shall only be removed from suicide watch after approval by mental health staff after a suicide risk assessment indicates it is safe to do so. Mental health staff shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. The County shall revise observation logging procedures and practices to ensure that sufficiently detailed information about an irunate's suicide watch is recorded at appropriate intervals. At the time of placement on suicide watch, medical or mental health staff shall write orders setting forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils. These conditions shall be altered only on the written instruction of the mental health staff, except under emergency circumstances.
62. Location of Suicide Watch The County shall review and alter as necessary one medical area cell for inmates to be placed for suicide watch, ensuring that physical features that could aid in completion of a suicide are altered or removed, and that staff conducting suicide watch can see every point in the room. Only cells in the medical area shall be used for suicide watch. On occasions when more than one inmate must be placed on suicide watch at the same time, the County shall institute precautions to maintain the safest environment possible for those inmates, and ensure adequate supervision.
63. Risk Assessment The County shall ensure that any inmate showing signs and symptoms of suicide is assessed using an appropriate suicide risk assessment instrument. V. SECURITY AND SAFETY
A. Inmate Supervision 64. Correctional personnel The County shall staff the master control center; each housing unit, including administrative and disciplinary segregation; booking; the kitchen area and the
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medical area with adequate correctional personnel to protect inmates from unreasonable risks of harm. Staff may be aided by appropriate monitoring equipment maintained in working order.
65. Monitoring equipment The County shall maintain in working order all monitoring equipment at the Detention Center.
B. Grievances and Investigations 66. Filing of grievances The County shall develop and implement an effective inmate grievance system, ensure that grievances may be filed confidentially where the filing of such grievance might expose the inmate or a third party to imminent danger. The County shall also ensure that grievances receive appropriate follow-up, including informing the grievant of its outcome and tracking implementation of resolutions. 67. Investigations The County shall develop and implement policies, procedures and practices regarding intemal investigations to ensure that management has a mechanism for identifying problems and appropriate remedies. The County shall maintain staffing sufficient to meet such internal investigation responsibilities. C. Booking Area 68. Safety The County shall provide for the safety and security of inmates in the booking area. The booking area shall not be used for protective custody, administrative segregation, punitive segregation or other special custody status detention, absent emergency circumstances, but may be used for temporary detention of intoxicated individuals pursuant to New Mexico Statutes Annotated (NMSA), NMSA 1978 §§ 43-2-2 through 43-2-22.
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69. Hygiene The County shall provide inmates detained in the booking area with appropriate shower opportunities.
D. Inmate Classification 70. Classification System The County shall develop and implement an appropriate classification system to protect inmates from unreasonable risk of harm. Inmates shall be timely classified and placed in housing appropriate for security and safety. The County shall use best efforts to anticipate periods of unusual intake volume and schedule sufficient classification staff to timely classify inmates. E. Information Regarding Constitutionally Required Services 71. Access to Information Regarding Constitutionally Required Services The County shall ensure that newly admitted inmates receive information they need to comply with facility rules and regulations, be protected from harm, report misconduct, access medical and mental health care and seek redress of grievances. VI. QUAI.ITY MANAGEMENT 72. Quality Assurance System The County shall develop and implement quality assurance policies, procedures and practices to evaluate and make necessary changes to medical and mental health care, suicide prevention, security and safety at the facility. VII. STAFF TRAINING AND SUPERVISION 73. Training Regarding this Agreement The County shall provide training and supervision to staff sufficient to implement the provisions of this Agreement.
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VIII. DOJ MONITORING OF AGREEMENT. TIME FRAME FOR SUBSTANTIAL COMPLIANCE, AND TERMINATION OF THE AGREEMENT 74. Termination This Agreement shall terminate three years from the date this Agreement
is executed by the parties. The Agreement may terminate sooner pursuant to paragraphs 75-80 below.
75. Satisfaction of the Agreement. Early Termination and Stipulation of Dismissal ''Substantial Compliance" with each and every term of this Agreement for a period of nine months shall fully satisfy the Agreement. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance, shall not constitute failure to maintain substantial compliance. At the same time, temporary compliance during a period of otherwise sustained noncompliance shall not constitute substantial compliance. This Agreement may be terminated prior to the conclusion of the three year period described in paragraph 74 if the County demonstrates that it has reached substantial compliance with all provisions of this Agreement and has sustained it for nine months. After substantial compliance with all provisions of this Agreement for a period of nine months, the DOJ and the County will execute a Termination of Agreement that confirms that the commitments contained in this Agreement have been satisfied and which relieves the parties from further monitoring and reporting. The tennination document shall contain the following statement: "The DOJ agrees that termination of this Agreement is appropriate. There is no current pattern or practice of the County or its contractors violating the inmates' constitutional rights addressed in our Agreement at the Santa Fe County Adult Detention Center."
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76. Review and Approval All policies, procedures, plans and protocols required by or referenced in this Agreement shall be submitted to the United States for review and approval within ninety (90) calendar days of the execution of this Agreement. Other written documents described in paragraph 10 shall be developed and submitted within one hundred eighty {180) days of the date this Agreement is executed by the parties. The United States shall provide written guidance to the County, including specific explanations as to how the provisions, policies, procedures and other written documents are inconsistent with the terms of the Agreement, and shall suggest revisions, within sixty (60) calendar days of the date they are received, from the County, absent exceptional circumstances. All policies and procedures shall be deemed approved unless objected to in writing as provided herein. In the event that the United States asserts that policies, procedures, and other written documents are not in compliance with the terms of this Agreement, the parties will agree to a schedule for the parties' experts to communicate and for the County to submit revisions. If, after the policies, procedures, and practices affected by this Agreement are implemented, either of the parties dctennines that a policy, procedure, protocol, plan or practice, as implemented, fails to effectuate the terms of this Agreement, the County shall consult with the United States and revise the policy, procedure or practice as necessary to effectuate the terms of this Agreement. The County shall maintain sufficient records to document its compliance with all requirements ofthis Agreement.
77. Implementation The County shall implement policies, procedures, plans and protocols approved by the United States within ninety (90) calendar days of notice of approval, to the extent that such policies have not already been implemented.
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78. Compliance Reporting The County shall prepare and submit to the United States reports regarding compliance with each paragraph containing substantive requirements in articles III through VII of this Agreement. The County shall submit the first report within one hundred and twenty (120) days of the date this agreement is executed until substantial compliance is reached or the Agreement terminates pursuant to paragraph 74. The reports shall include a summary of steps taken to implement the Agreement, along with suppm1ing documentation and certifications. Upon achieving substantial compliance as determined by DOJ with any substantive paragraph(s) of this Agreement for nine months, no further reporting shall be required on that paragraph.
79. Certification of Compliance The County may at its option submit to the United States a written certification of compliance with any substantive paragraph(s) of this agreement by facsimile or overnight delivery. The certification shall provide evidence of compliance. If representatives of the United States do not provide written objection to such certification within forty-five (45) calendar days of receipt, the County will be deemed in substantial compliance with the specified paragraph(s) beginning on the date of delivery of the certification.
80. Compliance Monitoring DOJ representatives of the United States, including its experts, may conduct periodic on-site compliance monitoring tours. The dates and duration of each on-site compliance monitoring visit shall be determined by DOJ representatives in consultation with the County. The County shall provide DOJ representatives with reasonable access to inmates and staff, documents, and information relating to implementation of this Agreement. DOJ shall have the right to conduct confidential interviews with inmates, and to conduct interviews with facility staff outside the presence of other staff or supervisors. To the extent that the County proceeds in good faith to implement the terms outlined in this Agreement,
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DOJ shall conduct exit interviews on the final day of each monitoring tour and shall provide the County with any written reports completed by DOJ experts regarding the Detention Center. DOJ shall identify any deficiencies promptly following the monitoring tours.
81. Scope of Compliance Neither the DOJ nor its experts shall add provisions or expand the scope of this Agreement in any manner.
82. Non-compliance If after reasonable notice to the County and an opportunity to cure any deficiencies identified in writing, the United States determines that the County has not substantially complied with this Agreement, the United States may pursue litigation against the County. Notwithstanding the foregoing, the United States reserves the right to file a complaint against the County at any time if it believes the County is not making a good faith effort to substantially comply with this Agreement. The United States shall give the County fourteen (14) calendar days' written notice before filing such a complaint.
83. Confidentiality Any information or documents obtained pursuant to this Agreement shall not be disseminated, except as provided by law, to any person not a party (or an employee or contractor of a party) to this Agreement. In the event of a request under the Freedom of Information Act ("FOIA"), or any other statute or provision of law, by a third party for disclosure of any information or documents provided by the County to the United States, the United States will assert all applicable exemptions from disclosure permitted by law. Additionally, the United States will notify the County of any such request if the United States intends to disclose any documents.
84. Disputes Should the County disagree with the DOJ or its experts' recommendations or findings regarding substantial compliance, the County may retain its own cxpert(s). The parties' experts will thereafter confer in an attempt to reach agreement. In the event that the parties are
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unable to reach agreement, the parties' experts will select a neutral third party expert. The parties agree to be bound by the opinion of this third party expert concerning the issues upon which he or she is asked to make findings.
85. Successors This Agreement shall be binding on all successors, assignees, employees, and all those working for or on behalf of the County.
86. Defense of Agreement The parties agree to defend the provisions of this Agreement. The parties shall notify each other of any court challenge to this Agreement. In the event any provision of this Agreement is challenged in any local or state court, removal to a federal court shall be sought.
87. Enforcement Failure by either party to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.
88. Unforeseen Delay If any unforeseen circumstance occurs which causes a failure to timely carry out any requirements of this Agreement, the County shall notify DOJ in writing as soon as possible, but no later than 20 calendar days of the time that the County becomes aware of the unforeseen circumstance and its impact on the County's ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. The County shall implement all reasonable measures to avoid or minimize any such failure.
89. Non-Retaliation The County agrees that it shall not retaliate against any person because that person has filed or may file a complaint, provided information or assistance, or participated in any other manner in an investigation or proceeding relating to this Agreement.
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/s/ R. Alexander Acosta /s/ Bradley J. Schlozman /s/ Shanetta Y. Cutlar

/s/ Mark S. Masling /s/ Dana L. Shoenberg

/s/ Paul D. Campos /s/ Greg Solano /s/ Stephen C. Ross

APPENDIX A
Medical staffing
Nursing
(12) hours on-site registered nurse coverage daily.
Mid-level practitioner
Minimum of forty (40) hours per week on-site nurse practitioner or physician's assistant. Scheduling of clinical staff
Hours of registered nurses, nurse practitioners and physicians' assistants shall be scheduled so that at least one of those professionals is at the facility sixteen (16) hours per day, five (5) days per week, during the hours when there is the most inmate activity. The remaining eight (8) hours of each weekday and the remaining twelve (12) hours per day on weekends may be covered by LPNs.
Physician
Minimum of sixteen (16) hours on-site physician per week, or, in the alternative, physician is onsite at the facility at least portions of four days per week. Physician must fulfill all responsibilities outlined in paragraphs 13 and 15.
Physician emergency on-call
24-hour daily on-call physician coverage.
Mental Health Staffin~
Psychiatrist
Minimum of twelve (12) hours of on-site psychiatrist per week, or, in the alternative, on-site psychiatrist at least portions of three (3) days per week. Half of the "on-site" hours may be accomplished through video conferencing. Psychiatrist must fulfill all responsibilities outlined in paragraph 14.
Psychiatrist emergency on-call
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., 24-hour daily on-ca1l psychiatrist coverage. Other Mental Health Staff Daily mental health care staff present from 8 a.m. to 5 p.m. Monday through Friday. On-call Mental Health Coverage 24 hours on weekends
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..
...
APPENDIXB Topics to be covered in intake medical questioning include whether inmates:
have any current health problems or are pregnant; are on or have recently been on any medications; have previously attempted suicide; are thinking about or platming to commit suicide; - have a history of psychiatric hospitalization or treatment; - hold a position of respect in the conununity; currently are feeling helpless or hopeless; - arc under the influence of any substance. Officers shall also observe whether inmates: appear to be unusually embarrassed, ashamed or upset; are acting in a strange manner such as hearing or seeing things that are not there; appear to be under the influence of drugs or alcohol.
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