case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 1 of 8
' '• "·
IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA.,... .. HAI\IMOND DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

)

v.

)

)

LAKE COUNTY, INDIANA;

)

ROGELIO "ROY" DOMINGUEZ, LAKE

)

COUNTY SHERIFF, in his official capacity only; )

FRANCES DUPEY, President, Lake County

)

Board of Commissioners, in her official capacity )

only; THOMAS C. O'DONNELL, President,

)

Lake County Council, in his official capacity only; )

LAKE COUNTY BOARD OF

)

COMMISSIONERS, in their official capacity

)

only; LAKE COUNTY COUNCIL, in their

)

official capacity only,

)

)

Defendants.

)

___________________

)
)

CIVIL ACTION NO:
2 lSCV-4
COMPLAINT FOR VIOLATIONS OF THE CIVIL RIGHTS OF I~STITUTIONALIZED PERSONS ACT
42 u.s.c. §§ 1997-1997j

COMPLAINT
PLAINTIFF, THE UNITED STATES OF AlvfERICA ("Plaintiff'), by its undersigned attorneys, hereby alleges upon information and belief: 1. The Attorney General files this Complaint on behalf of the United States of America
pursuant to the Civil Rights oflnstitutionalized Persons Act of 1980, 42 U.S.C. § 1997, to enjoin the named Defendants from depriving persons incarcerated at the Lake County Jail ("LCJ") in Crown Point, Indiana, of rights, privileges, or immunities secured and protected by the Constitution of the United States.

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JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under 28 U.S.C. § 1345. 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 ofthe Attorney General is appended to this Complaint as Attachment A and is incorporated herein. 5. Venue in the United States District Court for the Northern District of Indiana is proper pursuant to 28 U.S.C. § 1391.
PARTIES 6. Plaintiff is the United States of America. 7. Defendant LAKE COUNTY (the "County") is a governmental subdivision created under the
laws of the State oflndiana and governed by the Defendants LAKE COUNTY BOARD OF COMMISSIONERS and LAKE COUNTY COUNCIL. Defendant LAKE COUNTY through Defendant LAKE COUNTY BOARD OF COMMISSIONERS has the responsibility to maintain LCJ. Defendant LAKE COUNTY through Defendant LAKE COUNTY COUNCIL has responsibility for funding the operations ofLCJ. 8. Defendant LAKE COUNTY BOARD OF COMMISSIONERS functions as the county executive and is responsible for supervising the care and custody of all Lake County property. The Lake County Board of Commissioners is sued in their official capacity. 9. Defendant LAKE COUNTY COUNCIL functions as the County's legislative body as well as its fiscal body. The Lake County Council is sued in their official capacity. 10. Defendant FRANCES DUPEY is the President of the Lake County Board of Commissioners. Frances DuPey is sued in her official capacity.

case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 3 of 8
-311. Defendant THOMAS C. O'DONNELL is the President of the Lake County Council.
Thomas C. O'Donnell is sued in his·officia1 capacity. 12. Defendant ROGELIO "ROY" DOMINGUEZ, is the Lake County Sheriff, an
independently-elected constitutional officer not under the authority of the County Board of Commissioners or the County Council. IN. Const. Art. VI, § 2(a). Defendant Rogelio "Roy" Dominguez has responsibility for the operations of LCJ and to protect the safety of inmates. Sheriff Dominguez is sued in his official capacity. 13. Defendants LAKE COUNTY and Sheriff DOMINGUEZ are together responsible for the conditions of confinement and health and safety of persons incarcerated at LCJ. 14. Defendants are legally responsible, ·in whole or in part, for the operation and conditions of LCJ, and for the health and safety of persons incarcerated there. Defendant County owns LCJ; Defendant County Board of Commissioners is responsible for maintaining LCJ; Defendant Sheriff is responsible for the operations ofLCJ, and Defendant County Council is responsible for funding the operations and maintenance of LCJ. This action concerns the administration of persons confined at LCJ, which houses adult male and female inmates who are felons, gross misdemeanants, misdemeanants, pre-trial detainees, juvenile offenders, witnesses, or others being detained in protective custody. 15. At all relevant times, defendants or their predecessors in office have acted or failed to act, as alleged herein, under color of state law.
FACTS 16. LCJ is an institution within the meaning of 42 U.S.C. § 1997( 1). 17. Persons confined to LCJ include both pre-trial detainees and sentenced inmates.

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18. Defendants have repeatedly, deliberately, and consistently disregarded known or serious risks of harm to inmates at LCJ.
19. Defendants have repeatedly failed to take reasonable measures to protect inmates against the serious harm from suicide and self harm due to, but not limited to: (I) inadequate suicide prevention measures; (2) lack of appropriate screening by a qualified mental health professional to assess suicide risk; (3) lack of appropriate supervision, observation, and monitoring of inmates identified as at risk of suicide; (4) inadequate communication between eorreetional health care and correctional staff; (5) the lack of appropriate multidisciplinary treatment plans; and (6) the lack of appropriate medication administration.
20. Defendants have repeatedly failed to provide adequate mental health services, including psychological and psychiatric services, to inmates with serious psychiatric needs that are known or obvious due to, but not limited to, insufficient and inadequate: (I) staffing; (2) intake and referral processes; (3) sick call process; (4) treatment planning and services; (5) medication management; and (6) quality improvement and quality management programs.
21. Defendants have repeatedly failed to provide adequate medical care to address inmates' serious medical needs and have caused inmate harm and created an unreasonable risk of harm due to, but not limited to: (1) insufficient medical staffing; (2) inadequate access to medical care; (3) inadequate acute and chronic medical care; (4) inadequate comprehensive health assessments; (5) poor medication administration; (6) inadequate medical records; and (7) lack of a quality improvement system to monitor for and correct inadequate care.

case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 5 of 8
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22. Defendants have pervasively failed to provide adequate fire safety, resulting in risks of grave hann to inmates and staff from smoke, fire, and the serious security concerns that arise during an emergency due to fire.
23. Defendants have pervasively maintained a physical environment at LCJ that causes harm and poses an unreasonable risk of serious hann to inmates' health and safety by failing to correct facility housing and maintenance problems in addition to inadequate housekeeping, laundry and food services that causes harm or poses a risk of harm to the inmates and staff within the facility.
24. The factual allegations set forth in paragraphs 16 through 23 have been obvious and known to Defendants for a substantial period oftime, yet Defendants have deliberately failed to adequately address the conditions described.
VIOLATIONS ALLEGED 25. The allegations of Paragraphs I through 24 are hereby re-alleged and incorporated by
reference. 26. Through the acts and omissions alleged in paragraphs 16 through 24, Defendants have
exhibited deliberate indifference to the health and safety of CCH 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. Canst. Amends. VIII and XIV. 27. Unless restrained by this Court, Defendants will continue to engage in the acts and omissions, set forth in paragraphs I6 through 24, that deprive persons confined in LCJ privileges or irnrnunities secured or protected by the Constitution of the United States.

case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 6 of 8
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PRAYER FOR RELIEF 28. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and
declaratory relief. 29. WHEREFORE, the United States prays that this Court enter an order:
a. declaring that the acts, omissions, and practices of Defendants set forth in paragraphs 16 through 24 above constitute a pattern or practice of conduct that deprives inmates confined at LCJ of rights, privileges, or immunities secured or protected by the Constitution of the United States and that those acts, omissions, and practices violate the Constitution of the United States;
b. 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 practices set forth in paragraphs 16 through 24 above and requiring Defendants to take such actions as will ensure lawful conditions of confinement are afforded to inmates at LCJ; and
c. granting such other and further equitable relief as it may deem just and proper. Respectfully submitted,
FOR THE UNITED STATES:

case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 7 of 8

-7

:ZSAS~P~

Assistant Attorney General Civil Rights Division

.

,.<R-LO~,Y/z L/AI \~\~ ~R"._"_\

\

,
' \

Deputy Assistilll1 Att()rru:y-<Jeneral

Civil Rights Division

Deputy Chief
Special Litigation Section
i..«U G:. Sa~uJ/; ~ 4Af
LUIS E. SAUCEDO Acting Deputy Chief Special Litigation Section
IU.tiA.trm. e?. JA..IJ~
MATTIIEW J. DONNELLY WILLIAM G. MADDOX Senior Trial Attorneys U.S. Department of Justice Civil Rights Division Special Litigation Section- PHB 950 Pennsylvania Avenue, NW Washington, D.C. 20530 (202) 514-6255 matthew.donnelly@usdoj.gov

case 2:10-cv-00476-TLS-PRC document 1 filed 12/03/10 page 8 of 8
®ffitf of f~l' .!tfotnf{;? <!!)fntral llllu.t~ington, JD. <!I. 2ll.S:30

CERTIFICATE OF THE ATTORNEY GENER:\L

I, Eric H. Holder, Jr., Attorney General ofthe United States, certizy that with regard to the foregoing Complaint, United States v. Lake County. Indiana, I have complied with all subsections of 42 U.S.C. § 1997b(a)(l). I certey as well that I have complied with all subsections of 42 U.S.C. § 1997b(a)(2). I further certizy, pursuant to 42 U.S. C.§ 1997b(a)(3), my belief that this action by the United States is of general public importance and will materially further the vindication of rights, privileges, or immunities secured or protected by the Constitution.

In addition, I certizy that I have the "reasonable cause to believe," set forth in 42 U.S.C. § 1997a, to initiate this action, and that all prerequisites to the initiation of this suit under 42 U.S. C. §§ 1997a and 1997b have been met.

Pursuant to 42 U.S.C. § 1997a(c), I have personally signed the foregoing

Complaint. Pursuant to 42 U.S.C.§ 1997h(b), I am personally signing this

Certificate.

·

Signed this 23rd day of November

, 2010, at Washington, D.C.

'
ERIC H. HOLDER, Jr. Attorney General of the Unite

 
 case 2:10-cv-00476-TLS-PRC document 12 filed 12/20/10 page 1 of 2

IN THE UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

)

)

v.

)

)

LAKE COUNTY, INDIANA;

)

ROGELIO “ROY” DOMINGUEZ, LAKE

)

COUNTY SHERIFF, in his official capacity only; )

FRANCES DUPEY, President, Lake County

)

Board of Commissioners, in her official capacity )

only; THOMAS C. O’DONNELL, President,

)

Lake County Council, in his official capacity only; )

LAKE COUNTY BOARD OF

)

COMMISSIONERS, in their official capacity

)

only; LAKE COUNTY COUNCIL, in their

)

official capacity only,

)

)

Defendants.

)

)

_________________________________________ )

CAUSE NO. 2:10-CV-476-TLS

ORDER

The United States of America, Plaintiff, and Lake County, et al., Defendants, have

determined that the interests of all concerned parties can best be served by entering into a

settlement agreement to resolve the above-captioned case concerning conditions of confinement

at the Lake County Jail in Crown Point, Indiana. In recognition of these interests and to avoid

the burdens of adversarial litigation, the parties have entered into a settlement agreement (Lake

County Jail Settlement Agreement, ECF No. 9 at 6–38), which is attached to their Joint Motion

to Enter Settlement Agreement [ECF No. 9], and have moved this Court for entry of the

Settlement Agreement as an Order.

case 2:10-cv-00476-TLS-PRC document 12 filed 12/20/10 page 2 of 2

Having reviewed the parties’ Joint Motion to Enter Settlement Agreement and for good

cause shown:

The Court GRANTS the Joint Motion to Enter Settlement Agreement [ECF No. 9] and

APPROVES the Settlement Agreement in its entirety. The court shall retain jurisdiction over

this matter to ensure timely and proper implementation of the Settlement Agreement.

The Court further FINDS that the Settlement Agreement complies in all respects with the

provisions of 18 U.S.C. § 3626(a). The prospective relief in the Settlement Agreement is

narrowly drawn, extends no further than necessary to correct the violations of federal rights, is

the least intrusive means necessary to correct these violations, and will not have an adverse

impact on public safety or the operation of a criminal justice system.

SO ORDERED on December 20, 2010.

THERE UNITED FORT

s/ Theresa L. Springmann SA L. SPRINGMANN STATES DISTRICT COURT WAYNE DIVISION

2

 
 case 2:10-cv-00476-TLS-PRC document 9 filed 12/03/10 page 6 of 38
LAKE COUNTY JAIL SETTLEMENT AGREEMENT
I. INTRODUCTION
1. On September 12,2008, the Civil Rights Division ofthe United States Department ofJustice ("United States") notified Lake County, Indiana, officials of their intention to investigate conditions of confinement at the Lake County Jail ("LCJ" or "the facility"), pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA").
2. On December 15-18, 2008, the United States toured LCJ with consultants in the fields of correctional suicide prevention, mental health care, medical care, fire safety, and environmental health.
3. Throughout the course of the investigation, the Lake County Sheriffand other Lake County officials provided the United States with complete cooperation and access to LCJ and all documents.
4. On December 7, 2009, the United States issued a "Findings Letter" pursuant to 42 U.S.C. § 1997 that concluded that certain conditions at LCJ violate the constitutional rights of individuals LCJ confines.
5. The parties enter into this Settlement Agreement ("Agreement"), which will be flied in the United States District Court, Northern District oflndiana, Hanunond Division to effectuate the Agreement, for the purpose of clearly articulating and further complying with Lake County's duties under state and federal law. The parties agree this Agreement neither constitutes an admission by Lake County ofthe truth of any of the findings contained in the DOJ's Findings Letter of December 7, 2009, and does not and shall not constitute any admission of fault or liability by Lake County, the Lake County Sheriff and/or any of their elected officials, agents, servants or employees.
6. This Agreement does not constitute an admission that any ofthe provisions herein have not been complied with prior to the execution of this Agreement and any and all such deficiencies, risks, or breach(es) intimated by the language of this Agreement, express or implied, are hereby specifically disclaimed by Lake County.
7. The parties to this Agreement are the United States, represented by the United States Department of Justice, and Lake County, Indiana, represented by the Lake County Sheriff in his official capacity, the Lake County Commissioners in their official capacities, the Lake County Council, in its official capacity and each of their of their respective agents, assigns, employees, designees and successors in office, in their official capacities. Lake County will use its best efforts to ensure that the Lake County Jail takes all actions necessary to comply with all provisions contained in this Agreement.
8. Lake County enters into this Agreement because it is firmly committed to continue to provide constitutionally and legally compliant conditions in the Jail, by efTectuating its duties under the Constitution and other applicable laws.

Settlement Agreement LC Jail-OOJ {8~15-2010)_wpd

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9. This Agreement is not intended to have any preclusive effect except between the parties hereto and should the issue of the preclusive effect of this Agreement be raised in any proceeding, other than one to enforce this Agreement, the parties agree to certify that this Agreement was intended to have no such preclusive effect.
10. This Agreement will not and cannot be used against Lake County in any proceeding other than a proceeding between the United States and Lake County for enforcement of the terms and conditions contained in this Agreement.
11. No person or entity is intended to or shall be a third-party beneficiary ofthe terms, conditions or provisions ofthis Agreement for purposes of any civil, criminal, or administrative action. Accordingly, no person or entity may assert any claim or right as a beneficiary or protected person or class under this Agreement. This Agreement is not intended to impair or expand the right ofany person, entity or organizationto seek reliefagainst Lake County or its elected officials, employees, or agents for their past or future conduct; accordingly, this Agreement does not alter any legal standards governing any such claims, including those under any Federal or Indiana law.
12. Lake County is responsible for providing or obtaining all support, including financial resources, necessary to fulfill its obligations under this Agreement. Since the DOJ conducted its inspection in December of 2008, Lake County has and continues to make progress in implementing the reconunendation contained in the Findings Letter and shall, within ninety (90) days of the effective date of this Agreement, authorize a bond issue of up to $565,105 for the costs offacility repairs and other expenses necessary to carry out this Agreement. The funds from the bond issue will be used in part to (a) acquire a system for the electronic entry and storage ofeach imnate's medical and mental health records and (b) to update the shower facilities in the LC Jail to facilitate the ease of maintaining said facility in a clean and sanitary condition.
13. Nothing in this Agreement shall prevent the Sheriff or Lake County from modifying the LC Jail facilities or developing alternative placements programs for the detainees currentlyat the LC Jail and nothing in this Agreement shall be construed so as to prohibit the County from engaging a third party to perform any ofthe responsibilities ofrequired by the County or the LCJ under this Agreement.
14. This Agreement resolves the CRIPA investigation conducted by the DOJ and addresses the corrective measures set forth by the DOJ in its December 7, 2009, Findings Letter to Lake County and, in conformity with CRIPA, this Agreement represents a voluntary effort by Lake County to address the alleged constitutional violations raised by the DOJ's investigation in its Findings Letter. CRIPA, 42 U.S.C. §§ 1997b(a)(2)(B) & 1997g.

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II. DEFINITIONS
1. "LCJ" or "the fucility" mean the Lake County Jail, currently located on 2293 North Main Street in Cmwn Point, Indiana, as well as any facility that is built, leased, or othernise used, to replace or supplement the LCJ.
2. "DOJ" means the United States Department of Justice, which represents the United States in this matter.
3. "Effective date" means the date the Agreement is signed by the parties.
4. "Include" or "including" means "include, but not be limited to" or "including, but not limited to. 11
5. "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 the LCJ.
6. Consistent Vlith, or in accordance with, the term "generallv accepted correctional standards of care" means 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.
7. "Qualified Medical Professional" means a licensed physician, licensed physician assistant, or a licensed nurse practitioner, who is currently licensed by the State of Indiana to deliver those health care services he or she has undertaken to provide.
8. "Qualified Medical Staff' means Qualified Medical Professionals and Qualified Nursing
Staff.
9. "Qualified Mental Health Professional" means an individual with a minimum of masterslevel education and training in psychiatry, psychology, counseling, social work or psychiatric nursing, who is currently licensed by the State of Indiana to deliver those mental health services he or she has undertaken to provide.
I0. "Qualified Mental Health Staff' means individuals with a minimum of a bachelor's degree and two years of experience providing mental health services.
11. "Qualified Nursing Staff' means registered nurses and licensed practical nurses currently licensed by the State of Indiana to deliver those health services they have undertaken to provide.
12. "Serious Suicide Attempt" means a suicide attempt that is considered to be either potentially life-threatening or that required medical treatment for serious harm.
13. "Suicide Precautions" means any level of watch, observation, or measures to prevent selfharm to inmates confined in the LCJ.

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14. "Train," means to instruct in the skills addressed to a level that the trainee has the demonstrated proficiency to implement those skills as, and when called for, in the training. "Trained" means to have achieved such proficiency.

15. "Correctional Officer" or "CO" shall mean merit correctional officers employed at the LCJ under the authority of the Sheriff and the Corrections Merit Board and shall not include civilian employees of the LCSD providing support services at or to the LCJ.

16. Throughout this Agreement, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance:

a. "Substantial Compliance" indicates that LCJ has achieved compliance with most or all components of the relevant provision of the Agreement.

b. "Partial Compliance" indicates that compliance has been achieved on some of the components of the relevant provision of the Agreement, but significant work remams.

c. "Non-Compliance" indicates that most or all of the components of the Agreement provision have not yet been met.

III. SUBSTANTIVE PROVISIONS

Lake County officials and LCJ shall take any actions necessary to achieve substantial compliance with the substantive provisions of the Agreement listed below. Lake County officials and LCJ shall implement and administer all the substantive provisions below in accordance with generally accepted correctional standards of care.

A. MEDICAL CARE.

I. LCJ shall provide adequate services to address the serious medical and mental health needs of all inmates.

2. LCJ shall develop and implement medical care policies, procedures, and practices to address and guide all medical care and services at LCJ, including, but not limited to the following:

(1) access to medical care; (2) continuity of medication; (3) infection control; (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; ( 11) comprehensive health assessments;

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(12) mental health; (13) women's health; (14) quality management; and (15) emergent response.

3. Intake Screening and Health Assessments.

a. LCJ shall develop and implement policies and procedures to ensure that adequate medical and mental health intake screenings and health assessments are provided to all inmates within 14 days.

b. LCJ shall ensure that, upon admission to LCJ, Qualified Medical Staff utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:

(1) medical, surgical, and mental health history, including current or recent medications;
(2) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcoho1and 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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any ofthese items shall be referred for timely medical evaluation, as appropriate.

c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 days of his or her arrival at LCJ shall include a complete medical history, physical examination, mental health history, and current mental status examination. The physical examination shall be conducted by Qualified Medical Staff. Records documenting the assessment and results shall become part of each imnate's medical record. A re-admitted inmate or an imnate 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 imnate's health status need not receive a new full physical health assessment. For such imnates, Qualified Medical Staff shall review prior records and update tests and examinations as needed.

d. LCJ shall ensure that Qualified Medical Staffattempt to elicit the amount, frequency and time ofthe last dosage of medication from every imnate reporting that he or she is currently or recently on medication, including psychotropic medication.

e. LCJ 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 24 hours of an imnate's arrival at LCJ, or sooner ifmedically necessary, Qualified Medical Staffshall decide

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case 2:10-cv-00476-TLS-PRC document 9 filed 12/03/10 page 11 of 38

whether to continue the same or comparable medication for serious medical needs. If the inmate's reported medication is discontinued or changed, a Qualified Medical Professional shall evaluate the inmate face-to-face as soon as medically appropriate and document the reason for the change.

f.

LCJ shall ensure that 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 Qualified Mental Health ProfessionaL Staff will constantly observe

such inmates until they are seen by a Qualified Mental Health Professional. Incoming

inmates reporting these conditions will be housed in safe conditions unless and until

a Mental Health Professional clears them for housing in a medical unit, segregation,

or with the general population.

g. LCJ shall ensure that all inmates at risk for, or demonstrating signs and symptoms of drug and alcohol withdrawal are timely identified. LCJ shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.

h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.

1.

LCJ shall ensure that correctional officers supervising newly arrived inmates

physically observe the conduct and appearance ofthese inmates to determine whether

they have a more immediate need for medical or mental health attention prior to or

following the intake health screening by Qualified Medical Staff.

4. Acute care.

a. LCJ shall provide adequate and timely acute care for inmates with serious and lifethreatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate eare will include timely medical appointments and follow-up medical treatment.

5. Chronic care.

a. LCJ shall develop and implement a written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.

b. LCJ shall adopt and implement appropriate written clinical practice guidelines for chronic and communicable diseases, such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, consistent with nationally accepted guidelines.

c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.

d. LCJ shall keep records of all care provided to inmates diagnosed Vi.ith chronic illnesses in the inmates' individual medical records.

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e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evaluate the status oftheir health and the effectiveness ofthe medication administered for their chronic conditions.

f.

LCJ shall ensure that inmates with disabilities or who need skilled nursing services

or assistance with activities of daily living shall receive medically appropriate care.

6. Treatment and Management of Communicable Disease.

a. LCJ shall develop and implement adequate testing, monitoring, and treatment programs for management ofcommunicable diseases, including tuberculosis ('TB"), skin infections, and sexually transmitted infections (''STis").

b. LCJ shall develop and implement infection control policies and procedures that address contact, blood bome and airbome hazards, to prevent the spread ofinfections or communicable diseases, including TB, skin infections, and STis. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.

c. LCJ shall continue to test all inmates for TB upon booking at LCJ and follow up on test results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LCJ shall follow current CDC guidelines for management of inmates with TB infection, including providing prophylactic medication when medically appropriate. If directed by a physician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagiousTB, and hospitali7.ed or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.

d. LCJ shall ensure that any negative pressure and ventilation systems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. LCJ shall document results of such testing.

e. LCJ shall develop and implement adequate guidelines to ensure that inmates receive appropriate wound care. Such guidelines will include precautions to limit the possible spread ofMethicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.

f. LCJ shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identity, treat, and control infectious diseases.

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7. Access to Health Care.

a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.

b. LCJ shall ensure that the medical request ("sick call") process for inmates is adequate and provides inmates with adequate access to medical care. The sick call process shall include:

(I) Vilritten medical and mental health care slips available in English, Spanish, and other languages, as needed;
(2) a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week;
(3) opportunity for illiterate inmates and imuates who have physical or cognitive disabilities to access medical and mental health care; and
(4) opportunity for all inmates, irrespective of primary language, to access medical and mental health care.

c. LCJ shall ensure that the sick call process includes logging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation ofthe date and summary ofeach request for care, the date the inmate was seen, the name ofthe person who saw him or her, the disposition ofthe 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. LCJ shall document the reason for and disposition of the medical or mental health care request in the inmate's medical record.

d. LCJ shall develop and implement an effective system for screening medical requests within 24 hours of submission. LCJ shall ensure sick call requests are appropriately prioritized based upon the seriousness of the medical issue.

e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.

f.

LCJ shall ensure that there is an adequate number of correctional officers to escort

inmates to and from medical units to ensure that inmates requiring treatment have

timely access to appropriate medical care.

g. LCJ shall ensure that Qualified Medical Staffmake daily rounds in the isolation areas to give imuates in isolation adequate opportunities to contact and discuss medical and mental health concerns with Qualified Medical Staffin a setting that affords as much privacy a~ reasonable security precautions vvi.ll allow. During rounds, Qualified Medical Staff will assess inmates for new clinical fmdings, such as deterioration of the imuate's condition.

h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care \\ill be provided regardless of the imuate's ability to pay. No fee-for-service shall be required for certain conditions, including

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health screenings, emergency care, and/or the treatment and care of conditions affecting public health, e.g., Tuberculosis, MRSA, pregnancy, etc., particularly for indigent inmates who are not covered by a health insurance plan or policy.
8. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates who receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimum, discharge instructions are obtained, appropriate Qualified Medical Staff reviews the information and documentation available from the visit, this review and the outside provider's documentation are recorded in the inmate's medical record, and appropriate follow-up is provided.
9. Emergency Care.
a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health needs receive timely and appropriate care, including prompt referrals and transports for outside care when medically necessary.
b. LCJ shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
I 0. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical and mental health needs of inmates at LCJ.
b. LCJ shall develop and implement policies, procedures, and practices to ensure timely responses to orders for medications and laboratory tests. Such policies, procedures, and practices shall be periodically evaluated to ensure timely implementation of clinician orders.
c. LCJ shall ensure that medical and mental health records are centralized, complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out ofLCJ for medical care. LCJ shall obtain records of care, reports, and diagnostic tests received during outside

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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.
e. LCJ shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
II. Medication Administration.
a. LCJ shall ensure that inmates receive necessary medications in a timely manner.
b. LCJ shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. LCJ shall provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
c. LCJ shall ensure that medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. LCJ shall ensure that medication administration is performed by Qualified Nursing Staffwho shall administer prescription medications on a directly-observed basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications without a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.
e. When LCJ has advance notice of the discharge of inmates with serious medical or mental health needs, LCJ shall provide such inmates with at least a seven-day supply of appropriate prescription medication, unless a different amount is deemed medically appropriate, to serve as a bridge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. LCJ 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 LC.J. LCJ shall ensure that information about potential release or transter of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a formal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications.
g. LCJ shall ensure that Qualified Medical Staff counsels all patients who refuse medication.
h. LCJ shall secure the medication room and discontinue allowing food to be stored in the medication refrigerator.

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12. Medical Facilities.

a. LCJ shall ensure that sufficient clinical space is available to provide inmates with adequate medical care services including:

(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric and
pregnant inmates).

b. LCJ shall ensure that medical areas are adequately cleaned and maintained, including installation of adequate lighting in medical exam rooms. LCJ shall ensure that hand washing stations in medical areas are fully equipped, operational and accessible.

c. LCJ shall ensure that appropriate containers are readily available to secure and dispose ofmedical waste (including syringes and sharp medical tools) and hazardous waste.

d. LCJ shall provide for inmates' reasonable privacy in medical care, and maintain confidentiality ofinmates' medical status, subject to legitimate security concerns and emergency situations.

13. Specialty Care.

a. LCJ shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at LCJ shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.

b. LCJ 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 Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.

c. LCJ 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, the reason for any missed or delayed appointments, and information on follow-up care, including the dates of any future appointments.

d. LCJ shall ensure that pregnant inmates are provided adequate pre-natal care. LCJ shall develop and implement appropriate vvritten policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment, and management of high risk pregnancies.

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14. Staffing. Training and Supervision.

a. LCJ shall ensure that its health care structure is organized with clear lines of authority tor its operations to ensure adequate supervision ofthe system's health care providers.

b. LCJ shall maintain sufficient staffing levels ofQualified Medical Staffand Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs.

c. LCJ shall ensure that all Qualified Medical Staff and Qualified Mental Health Staii are adequately trained to meet the serious medical and mental health needs of inmates. All such staff shall receive documented orientation and in-service training on relevant topics, including identification of inmates in need of immediate or chronic care, suicide prevention, and identification and care of inmates with mental illness. LC.T shall ensure that all other medical and mental health staff receive arlequate training to properly implement the provisions of this Agreement.

d. LC.T shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.

e. LCJ shall ensure that all persons providing medical or mental health treatment meet applicable state licensure and/or certification requirements, and practice onlyv..ithin the scope oftheir training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health ·staff have current, valid, and unrestricted professional licenses.

f. LCJ shall ensure that correctional officers are adequately trained in identification, timely referral, and proper supervisiop of inmates with serious medical needs. LCJ shall ensure that correctional officers lrre trained to understand and identify the signs and symptoms ofdrug and alcohol withdrawal and to recognize and respond to other medical urgencies.

g. LCJ shall ensure that correctional officers receive initial and periodic training on .basic mental health information (e.g.. recognizing mental illness, specific problematic behaviors, additional areas of concern); recognition of signs and symptoms evidencing a response to !trauma; appropriately responding to mental illness; proper supervision of inmates suffering from mental illness; and the appropriate use of force for inmates who suffer from mental illness. Such training shall be conducted by a Qualified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual.

15. Dental Care.

a. LCJ shall ensure that inmates receive <)dequate dental care, and follow up. Such care should be provided in a timely manner. Dental care shall not be limited to extractions.

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b. LCJ shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and related medical data, for every imnate who dies while in the custody of LCJ or under medical supervision directly from the custody ofLCJ.
b. LCJ shall conduct a mortality review for each inmate death while in custody and a morbidity review for all serious sulfide attempts or other incidents in which an inmate was at high risk for death. Mortality and morbidity reviews shall involve physicians, nurses, and other relevatltt LCJ perso!lllel and shall seek to determine whether there was a pattern ofsymptoms that might have resulted in earlier diagnosis and intervention. Mortality and morb,dity reviews shall occur within 30 days of the incident or death, and shall be revisit¢d when the final autopsy results are available. At a minimum, the mortality and motbidity reviews shall include:
(1) critical review and analysis of the cireumstances surrounding the incident; (2) critical review ofthe procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental health services/reports involving the victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures.
c. LCJ shall address any problems identified during mortality reviews through timely training, policy revision, and any other appropriate measures.
B. MENTAL HEALTH CARE.
1. LCJ shall provide adequate services to address the serious mental health needs ofall inmates, consistent w'ith generally accepted correctional standards ofcare, including sufficient staffing to meet the demands for timely access to an appropriate mental health proiessional, to ensure qualified mental health staff perform intake mental health screenings and evaluations, and to perform comprehensive assessments and comprehensive multidisciplinary treatment plalllling. See Section III. A.
2. Timelv and Appropriate Evaluation of Inmates.
a. LCJ shall develop and implement policies and procedures to provide adequate screening to properly identify and assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.
b. LCJ shall ensure that the intake health screening process referred to in Section I1I.A.2 includes a mental health screening, which shall be incorporated into the inmate's

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medical records. LCJ shall ensure timely access to a Qualified Mental Health Professional when presenting symptoms of mental illness require such care.
c. LCJ shall ensure that the mental health intake screening process includes inquiry regarding:
(I) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death ofa family member or close friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confmement; (7) any observations of the transporting officer, court, transferring agency, or
similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.
3. Assessment and Treatment.
a. LCJ shall ensure that any imnate who screens positively for mental illness or suicidal ideation during the intake screening process, or who is otherurise referred for mental health services, receives a comprehensive mental status evaluation in a timely manner from a Qualified Mental Health Professional (immediate for emergent issues, within 24 hours of referral for an expedited comprehensive evaluation, or 72 hours ofreferral 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 ofthe American Psychiatric Association. If Qualified Mental Health Staff find a serious mental illness, they shall refer the inmate for appropriate treatment. LCJ shall review available information regarding any diagnosis made by the inmate's community or hospital treatment provider, and shall account for the inmate's psychiatric history as a part ofthe assessment. LCJ shall adequately document the comprehensive mental status evaluation in the inmate's medical record.
b. LCJ shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate referrals for specialty care and regularly scheduled visits with Qualified Mental Health Professionals.
c. LCJ shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions speeifieally tailored to the inmates' diagnoses.
d. LCJ shall provide for an imnate's reasonable privacy in mental health care, and maintain confidentiality of inmates' mental health status, subject to legitimate security concerns and emergency situations.

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e. LCJ shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see such inmates in a timely manner.

f.

LCJ shall ensure timely and appropriate therapy, counseling, and other mental health

programs for all inmates with serious mental illness. This includes adequate space

for treatment, adequate number of Qualified Mental Health Staff to provide

treatment, and an adequate array of structured therapeutic programing.

g. LCJ shall ensure mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediate!y and regularly evaluated by a Qualified Mental Health Professional to determine the inmate's mental health status, which shall include an assessment of the potential effect ofsegregation on the inmate's mental health. During these regular evaluations, LCJ shall evaluate whether continued segregation is appropriate for that inmate, considering the assessment ofthe Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.

h. LCJ shall maintain an updated log ofinmates 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. Each clinician shall have ready access to a current log listing any prescribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and accurate information regarding any medication changes ordered in at least the past year.

1.

LCJ shall ensure that a Qualified Mental Health Professional conducts an in-person

evaluation ofan inmate prior to a medically-ordered seclusion or restraint, or as soon

thereafter as possible. Patients placed in medically-ordered seclusion or restraints

shall be evaluated on an on-going basis for physical and mental deterioration.

Seclusion or restraint orders should include sufficient criteria for release.

j.

LCJ shall ensure an adequate array of crisis services to appropriately manage the

psychiatric emergencies that occur among inmates. Crisis services shall not be

limited to administrative segregation or observation status. Inmates shall have access

to appropriate licensed in-patient psychiatric care, when clinically appropriate.

4. Psychotherapeutic Medication Administration.

a. LCJ shall ensure that psychotherapeutic medication administration is provided when appropriate.

b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physician on a regular, timely basis for appropriateness or adjustment. LCJ shall

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ensure that changes to inmates' psychotropic medications are clinically justified and documented.
c. LCJ shall ensure timely implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated \\-ith psychotropic medications are seen regularly by a physician to monitor responses and potential reactions to those medications, including movement disorders, and provide treatment where appropriate.
C. SUICIDE PREVENTION.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and procedures to ensure the appropriate management of suicidal inmates, and establish a suicide prevention program in accordance with generally accepted correctional standards of care.
b. The suicide prevention policy shall include, at a minimum, the following provisions:
(1) an operational description ofthe requirements for both pre-service and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
c. LCJ shall ensure suicide prevention policies include procedures to ensure the safe housing and supervision ofinmates based on the acuity of their mental health needs.
d. LCJ shall ensure security staff posts in all housing units are equipped with readily available, safely secured, suicide cut-down tools.
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
f. LCJ shall document inmate suicide attempts at LCJ in an inmate's correctional record in the classification system, in order to ensure that intake staffwill be aware ofpast suicide attempts if an inmate with a history ofsuicide attempts is readmitted to LCJ.
2. Suicide Precautions.
a. LCJ shall ensure that suicide prevention procedures include provisions for constant direct supervision ofactively suicidal inmates and close supervision ofspecial needs

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inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
b. LCJ shall ensure that when staff initially place an inmate on Suicide Precautions, the inmate shall be searched and monitored with constant direct supervision until a Qualified Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and wTites appropriate orders. Until such an assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified Medical or Mental Health Staff shall write orders setting forth the conditions ofthe watch, including but not limited to allowable clothing, property, and utensils. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Stati shall assess and interact with (not just observe) inmates on Suicide Precautions on a daily basis.
e. LCJ shall ensure that inmates v-.ill only be removed from Suicide Precautions after approval by a Qualified Mental Health Professional, in consultation with a
psychiatrbi, after a suicide risk assessment indicates it is sate to do so. A Qualified
Mental Health Professional shall wTite appropriate discharge orders, including treatment recommendations and required mental health follow-up.
3. Suicide Risk Assessments.
a. LCJ shall ensure that any inmate showing signs and symptoms ofsuicide is assessed by a Qualified Mental Health Professional using an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
b. LCJ shall ensure that the risk assessment shall include the following and findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record: (1) description of the antecedent events and precipitating factors; (2) suicidal indicators; (3) mental status exaruination;
(4) previous psychiatric and suicide risk history;
(5) level oflethality; (6) current medication and diagnosis; and (7) recommendations or treatment plan.

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4. Suicide Prevention Training.
a. LCJ shall review and, to the extent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:
(1) the suicide prevention policy as revised consistent with this Agreement; (2) why facility environments may contribute to suicidal behavior; (3) potential predisposing factors to suicide; (4) high risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) observation techniques; (7) searches of inmates who are placed on Suicide Precautions; (8) case studies of recent suicides and serious suicide attempts; (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-dov.n tools.
b. Within 12 months ofthe effective date ofthis Agreement, all LCJ staffmembers who work with inmates shall be trained on LCJ's suicide prevention program. Staffshall demonstrate competency in the verbal and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
D. I<"IRE SAFETY.
I. Fire Safety.
a. LCJ shall develop and implement a comprehensive fire satety program and ensure compliance is appropriately documented. The initial fire safety plan shall be approved by the State Fire Marshal or the Crov.n Point Fire Chief or Inspector. The fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever IS sooner.
b. LCJ shall ensure that comprellensive fire drills are conducted every three months on each shift. LCJ shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
c. LCJ shall ensure that LCJ has adequate fire and life safety equipment, including installation and maintenance offire alarms and smoke detectors in all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
d. LCJ shall ensure that all fire and life safety equipment is properly maintained and routinely inspected.

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e. LCJ shall ensure that emergency keys are appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual override in the event of an emergency in which the manual override is broken), including in the event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum ofthree times per year. LCJ shall conduct regular security inspections and provide ongoing maintenance to security devices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
g. LCJ shall implement competency-based testing for staffregarding fire and emergency procedures.
h. LCJ shall ensure that fire safety officers are trained in fire safety and have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
b. LCJ shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
c. LCJ shall ensure adequate ventilation throughout LCJ to ensure that inmates receive an adequate supply ofairflow and reasonable levels ofheating and cooling. LCJ shall review and assess compliance with this requirement at least twice annually.
d. LCJ shall ensure adequate lighting in all inmate housing and work areas and cover all light switches with exposed wires.
e. LCJ shall ensure adequate pest control throughout the housing units, medical units, and food storage areas.
f. LCJ shall ensure that all inmates have access to needed hygiene supplies.

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g. LCJ shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. LCJ shall ensure that any inmate or staff utilized to clean a biohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.

h. LCJ shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.

1.

LCJ shall inspect and replace as often as needed all frayed and cracked mattresses.

LCJ shall destroy any mattress that cannot be sanitized sufficiently to kill any

possible bacteria. LCJ shall ensure that mattresses are properly sanitized between

uses.

J.

LCJ shall ensure adequate numbers of staff to perfotrn housekeeping duties.

2. Sanitmy Laundrv Procedures.

a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.

b. LCJ shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards (e.g., at least twice per week), and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.

c. LCJ shall train staff and educate inmates regarding laundry sanitation policies.

d. LCJ shall ensure that laundry delivery procedures protect inmates from exposure to communicable diseases by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.

e. LCJ shall require inmates to provide all clothing and linens for LCJ laundering and prohibit inmates from washing and drying laundry outside the fotrnal procedures.

3. f'ood Service.

a. LCJ shall ensure that food service at LCJ is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures, and adequate meals are provided.

b. LCJ shall ensure that all food service statT, including inmate. staff, must be trained in food service operations, safe food hm1dling procedures, and appropriate sanitation.

c. LCJ shall ensure that kitchen(s) are staffed with a sufficient number of appropriately supervised and trained personnel.

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d. LCJ shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.

e. LCJ shall check and record, on a regular basis, the temperatures in the refrigerators, coolers, walk-in-refrigerators, the dishwasher water, and all other kitchen equipment v.ith temperature monitors to ensure proper maintenance offood service equipment.

F. QUALITY IMPROVEMENT AND QUALITY MANAGEMENT PROGRAM.

I. LCJ shall develop and implement written quality management policies and procedures to regularly assess, identifY, and take all reasonable measures to assure compliance with each of the provisions of this Agreement, as applicable.

2. LCJ shall develop and implement policies to address and correct deficiencies that are uncovered during the course of quality management activities, including monitoring corrective actions over time to ensure sustained resolution.

3. LCJ shall institute a Quality Improvement Committee and ensure that such committee meets on a monthly basis and that this committee includes representatives from medical, mental health, and custody staff.

4. Quality management programs related to medical and mental health care will utilize performance measurements to assess quality of care and timely access to care with quantitative and qualitative data analysis and trending over time and specifically shall address:

a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of
suicide attempts, monitoring of inmates on suicide observations or precautions; d. the appropriateness ofphysical plant facilities such as safe cells for management of
at risk inmates, and tollow-up and treatment tor those who may have engaged in suicidal or self-harm activities; e. the appropriateness oftreatment planning and treatment interventions for inmates in the mental health program; f. discharge planning for the effective management and continuity ofcare for inmates leaving the system; and g. the quality of medical records and other documentation.

G. PROTECTION FROM HA&'\11.

L Use of Force by Staff.

a. LCJ shall develop and maintain comprehensive and contemporary policies and procedutes surrounding the use of force and with particular emphasis regarding permissible and impermissible use of force.

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b. LCJ shall address the following impermissible uses offorce in its use offoree policy and in the pre-service and in-service training programs for correctional officers and supervisors:
(I) use of force as an initial response to verbal insults or inmate threats;
(2) use of force as a response to inmates' failure to follow instructions where there is no immediate threat to the safety of the institution, inmates, or staff, unless LCJ has attempted a hierarchy of nonphysical alternatives that are documented;
(3) use of force as punishment or retaliation;
(4) striking, hitting, or punching a restrained inmate;
(5) use of force against an inmate after the inmate has ceased to offer resistance and is under control;
(6) use of choke holds on an inmate; and
(7) use of unnecessary or excessive force.
c. LCJ shall develop and implement a policy to ensure that staff adequately and promptly report all uses of force.
d. LCJ shall ensure that use of force reports \'fill:
(1) be written in specific terms in order to capture the details of the incident;
(2) contain an accurate account ofthe events leading to the use offorce incident;
(3) include a description of the weapon or instrument(s) of restraint, if any, and the manner in which it was used;
(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;
(5) state the nature and extent of injuries sustained both by the inmate and staff member;
(6) contain the date and time medical attention was actually provided;
(7) describe, in factual terms, the type and amount of force used and precise actions taken in a particular incident and avoid use of "boiler plate" descriptions for describing force, such as, "inmate taken to the ground with the force that was necessary;" and

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(8) note whether a use of force was videotaped. If the use of force is not videotaped, the reporting correctional officer and supervisor will provide an explanation as to why it was not videotaped.

c. LCJ shall require prompt administrative review ofuse offorce reports. Such reviews shall include case-by-case review of individual incidents of use of force as well as more systemic review in order to identify patterns ofincidents. LCJ shall incorporate such information into quality management practices and take necessary corrective action.

f.

LCJ shall ensure that Qualified Medical Staff request that imnates sign a release of

medical records for the limited purpose of administrative and investigative review

of any incident involving an inmate injury. Qualified Medical Staff will document

the request and the inmate's response. LCJ will ensure that inmates receive adequate

medical care regardless of whether they consent to release their medical records.

g. LCJ shall ensure that management review of use of Ioree reports and inmate grievances alleging excessive or inappropriate uses offorce includes a timely review ofmedical documentation of inmate injuries as reported by Qualified Medical Staff, including documentation surrounding the initial medical encounter, an anatomical dravl'ing that depicts the areas of sustained injury, and information regarding any further medical care.

h. LCJ shall establish criteria that trigger referral for use of force investigations, including but not limited to, injuries that are extensive or serious; injuries involving fractures or head trauma; injuries ofa suspicious nature (including black eyes, broken teeth, injuries to the genitals, etc.); injuries that require treatment at outside hospitals; and reports of events by staff and inmates that are inconsistent.

1.

LCJ shall develop and implement a system to track all incidents of use of force that,

at a minimum, includes the following information:

(1) a tracking number; (2) the imnate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (I 0) external reviews and results (if applicable); (11) remedy taken (if appropriate); and ( 12) administrative sign-off.

J.

LCJ shall ensure that as part of a use of force incident package, security supervisors

shall ensure that photographs are taken of any and all reported injuries sustained by

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inmates and staff promptly following a use of force incident. The photographs will become evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.

k. LCJ shall establish an "early warning system" that \\-ill document and track correctional officers who regularly employ force on inmates and any complaints related to the excessive use of force, in order to alert LCJ administration to any potential need for retraining, problematic policies, or supervision lapses. Appropriate LCJ leadership, supervisors, and investigative staff shall have access to this information and monitor the occurrences.

I.

LCJ shall ensure that a supervisor is present during all planned uses of force.

m. Where there is evidence of staff misconduct related to inappropriate or unnecessary force against inmates, LCJ shall initiate appropriate personnel actions and systemic remedies, as appropriate. LCJ shall discipline appropriately any correctional officer found to have:

( l) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or other staff member for reporting the use of
excessive force; or (4) interfered or failed to cooperate with an internal investigation regarding use
of force.

n. LCJ shall develop and implement accountability policies and procedures for the effective and accurate maintenance, inventory and assignment ofchemical and other security equipment.

o. Use of Foree Training:

(1) LCJ shall develop an effective and comprehensive training program in the appropriate use of force.

(2) LCJ shall ensure that correctional officers receive adequate training in LCJ's use of force policies and procedures.

(3) LCJ shall ensure that correctional officers receive adequate training in use of force and defensive tactics.

(4) LCJ shall ensure that correctional officers receive pre-service and in-service training on reporting usc of force and completing use of force reports.

p. LCJ shall ensure that inmates may report allegations of the use of excessive forc.e orally to any LCJ stall' member, who shall reduce such reports to writing.

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q. LCJ shall ensure that Qualified Medical Staffquestion, outside the hearing of other inmates or correctional officers if appropriate, each inmate who reports for medical care with an injury, regarding the cause ofthe injury. If, in the course ofthe inmate's medical encounter, a health care provider suspects staff-on-inmate abuse, that health care provider shall immediately:
(1) take all appropriate steps to preserve evidence ofthe injury (e.g., photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator;
(3) adequately document the matter in the inmate's medical record; and
(4) complete an incident report.
r. LCJ shall develop, assign, and train a team of specialized use of force investigators that will be charged with conducting investigations ofuse of force incidents. These use offorce investigators shall receive at the outset oftheir assignment, specialized training in investigating use of force incidents and allegations.
s. LCJ shall ensure that incident reports, use of force reports and inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, that it is referred for investigation.
IV. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
1. LCJ shall submit a bi-annual compliance report to DOJ and the Liaison, the first of which shall be filed v:ithin 120 days ofthe date ofthis Agreement. Thereafter, the bi-annual reports shall be filed 30 days prior to the Liaison's bi-annual compliance tour until the Agreement is terminated.
2. Each compliance report shall describe the actions LCJ has taken during the reporting period to implement this Agreement and shall make specific reference to the Agreement provisions being implemented.
3. LCJ shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the DOJ at all reasonable times for inspection and copying. In addition, LCJ 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 DOJ.
4. DOJ and its attorneys, consultants, and agents shall have unrestricted access to LCJ, LCJ inmates, LCJ staff(including stafffrom any other outside medical or mental health sen-ices provider) and documents as is reasonably necessary to address issues affected by this Agreement.
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5. Excluding on-site tours, within 30 days ofreceipt ofwritten questions from DOJ concerning LCJ's compliance with the requirements of this Agreement, LCJ shall provide DOJ with v.ritten answers and any requested documents.

V. CONSTRUCTION, IMPLEMENTATION AND TERMINATION

1. DOJ Liaison.

a. LCJ shall implement all reforms necessary to effectuate this Agreement. The implementation of this Agreement will begin immediately upon the effective date.

b. 1be DOJ shall appoint a Liaison to ensure implementation of and substantial compliance v.ith the terms and conditions of this settlement Agreement by Lake County.

c. The DOJ may hire or consult, at the DOJ's expense, with such additional qualified staff as necessary to fulfill the duties required by the Agreement (''Liaison Team"). The Liaison is ultimately responsible for the findings ofthe Liaison Team. The DOJ Liaison Tearn will be subject to all the same access rights and confidentiality limitations, listed below, as the Liaison.

d. The Liaison shall have full and complete access to the LCJ, all facility records, inmate medical records, staff, and inmates. LCJ shall direct all employees to cooperate fully with the Liaison. The Liaison shall maintain all medical records and non-public information in a confidential manner.

e. The Liaison shall be permitted to initiate and receive ex parte communications with all parties and the Court.

f.

The Liaison shall tile with the Court and provide the parties with reports describing

the steps taken by LCJ to implement this Agreement and evaluate the extent to which

LCJ have complied with each substantive provision of the Agreement. The Liaison

shall issue an initial report four months after the effective date ofthis Agreement, and

then every six months thereafter, unless both parties otherwise agree in writing. The

reports shall be provided to the parties in draft form for comment at least two weeks

prior to their issuance. These reports shall be written with due regard for the privacy

interests ofindividual inmates and staffand the interest of LCJ in protecting against

disclosure of non-public information.

g. In each Liaison's report, the Liaison shall evaluate the status of compliance for each provision of the Agreement using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Non-compliance. In order to assess compliance, the Liaison shall review a sufficient number of pertinent documents to accurately assess current conditions; interview all pertinent staff; and interview a sufficient number of inmates to accurately assess current conditions. The Liaison shall be responsible for independently verifying representations from LCJ regarding

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progress toward compliance, examining supporting documentation where applicable. Each Liaison's report shall describe the steps taken to analyze conditions and assess compliance, including document~ reviewed and individuals inten•iewed, and the factual basis for each of the Liaison's findings.

h. The Liaison shall provide LCJ with technical assistance as requested by LCJ.

1.

Throughout the duration ofthis Agreement, the DOJ and its expert consultants and

agents shall maintain the confidentiality of all information provided pursuant to this

Agreement consistent with federal law.

j.

Except as required or authorized by the terms of this Agreement or the parties acting

together, the Liaison shall not: make any public statements (at a conference or

otherwise) or issue findings with regard to any aet or omission of Defendants or their

agents, representatives or employees, or disclose nonpublic information provided to

the Liaison pursuant to this Agreement. Any press statement made by the Liaison

regarding his or her employment must first be approved in writing by all parties. The

Liaison shall not testifY in any other litigation or proceeding with regard to any act

or omission of Defendants, LCJ, or any of its agents, representatives, or employees

related to this Agreement, nor testifY regarding any matter or subject that he or she

may have learned as a result of his or her performance under this Agreement.

Reports issued by the Liaison shall not be admissible against Defendants in any

proceeding other than a proceeding involving this case. Unless such conflict is

waived by the parties, the Liaison shall not accept employment or provide consulting

services that would present a conflict of interest with the Liaison's responsibilities

under this Agreement, including being retained (on a paid or unpaid basis) by any

current or future litigant or claimant, or such litigant's or claimant's attorney, in

connection with a claim or suit against Defendants, their departments, officers, agents

or employees. The Liaison is not a State/County or local agency or an agent thereof,

and accordingly the records maintained by the Liaison shall not be deemed public

records subject to public inspection. Neither the Liaison nor any person or entity

hired or otherwise retained by the Liaison to assist in furthering any provision of this

Agreement shall be liable for any claim, lawsuit, or demand arising out of the

Liaison's performance pursuant to this Agreement. This provision does not apply to

any proceeding before a court related to performance of contracts or subcontracts for

monitoring this Agreement.

2. Professional Corrections Administrator ("PCA").

a. In accordance with the National Institute ofCorrections' Technical Assistance Report 1011047 dated .March 1, 2010, Lake County shall, within 180 days of the effective date of this Agreement, initiate a search for and employ a Professional Corrections Administrator ("PCA") to serve as the warden of the LC Jail and oversee the day-today operations of the jail during the term of this Agreement.

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b. The PCA shall be selected by the Sheriffof Lake County but said selection shall not be made by the Sheriti prior to January 5, 201 L

c. The PCA shall have a minimum of: (i) a Bachelor's degree in criminal justice or other closely related field; (ii) 5 years experience in supervising a large correctional facility or an equivalent combination ofeducation and experience; and (iii) knowledge ofand experience in applying modem correctional standards.

3. Termination- Compliance.

a. This Agreement shall terminate when LCJ has achieved substantial compliance with the substantive provisions of this Agreement and has maintained that substantial compliance for one (1) year. If LCJ demonstrates substantial compliance, the one year period for maintenance of substantial compliance may include periods of continued substantial compliance which commenced prior to the effective date ofthis Agreement.

b. Noncompliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance, shall not constitute failure by the LCJ to maintain substantial compliance. However, intermittent compliance during a period of sustained noncompliance shall not constitute substantial compliance. The DOJ, in its good faith discretion, will determine whether Lake County has maintained substantial compliance for the one year period and any finding of substantial compliance may not be unreasonably withheld.

c. Subsections of this Agreement pertaining to specific subject matter areas, such as staffing and training, screening and treatment, access to care, chronic disease care, medication administration and management, emergency care, mental health care, and suicide prevention, may be terminated separately and independently from the provisious of the Agreement that have not yet reached substantial compliance, if Lake County reaches substantial compliance in these areas and maintains substantial compliance for one (I) year.

d. The burden shall be on Lake County to demonstrate it has achieved substantial compliance with a particular section ofthis Agreement, and the DOJ, in its good faith discretion, will determine whether Lake County has maintained substantial compliance in a specific subject matter area for the one (I) year period.

e. A finding of substantial compliance may not be unreasonably withheld by the DOJ. The DOJ may also release Lake County from the obligations of any specific provision of this Agreement if it concludes, in its good faith discretion, that Lake County has achieved a sufficient sustainable level of compliance with the provision.

f. If DOJ believes that Lake County has failed to substantially comply with any obligation under this Agreement, DOJ will, prior to seekingjudicial action to enforce the terms of this Agreement, give written notice of the failure to Lake County. The Parties shall conduct good-faith discussions to resolve the dispute. Ifthe Parties are

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unable to resolve the dispute within thirty (30) days of the DOJ's notice of failure, then:

(1) the parties may mutually agree to submit the issue(s) to mediation before an independent mediator selected by Agreement ofthe DOJ and the County; or

(2) Either party may move to invoke the jurisdiction ofthe U.S. District Court for the Northern Districtoflndiana, Hammond Division, to enforce or resolve the provisions of this settlement Agreement in dispute between the parties.

g. Failure by either party to enforce this entire Agreement or any provision thereofwith 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.

h. If any unforseen circumstance occurs that causes a failure to timely carry-out any
requirements ofthis Agreement, LCJ shaJI notify DOJ in writing within 20 calendar days after LCJ becomes aware of the unforseen circumstance and its impact on the LCJ'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. LCJ shall implement all reasonable measures to avoid or minimize any such failure.

i.

The Agreement shall be applicable to, and binding upon, all parties, elected officials

and their respective officers, agents, employees, assigns, and their successors in

office.

j.

In the event that any provision of this Agreement is declared invalid for any reason

by a court of competent jurisdiction, said finding shall not affect the remaining

provisions of this Agreement.

VI. STIPULATION PURSUANT TO THE PRISON LITIGATION REFORM ACT, 18 U.S.C. § 3626

1. The parties stipulate that this Agreement complies in all respects with the provisions of 18 l:.S.C. § 3626(a). The parties further stipulate that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights regarding suicide prevention, medical and mental health care, environmental safety, and protection from harm/use of force, is the least intrusive means necessary to
correct these violations, and will not have an adverse impact on public safety or the operation
ofa criminaljustice system. Accordingly, the parties agree and represent that this Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a).

2. The issue ofliability has not been litigated.

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3. The parties do not intend for this Agreement to have any preclusive effect except between the parties. Should the issue ofthe preclusive effect of this Agreement be raised, the parties agree to certifY that they intended for this A!,,>reement to have no such preclusive effect.

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case 2:10-cv-00476-TLS-PRC document 9 filed 12/03/10 page 36 of 38 FOR THE UNITED STATES:

THOMAS E. PEREZ

Assistant Attorney General

Civil Rights Division\

\

\

\

\

\

.

ROY L. AUS , JR.

\\

Deputy Assist<ihtcAtt,om~eral

Civil Rights Division

J U D,. Q i C
Deputy Chief Special Litigation Section

~ ~ 'Sat.u~.Jt; '
LUIS E. SAUCEDO Acting Deputy Chief Special Litigation Section

~

tu~ 6. !-(~!_~
WILLIAM G. MADDOX MATTHEW J. DONNELLY Attorneys U.S. Department ofJustice Civil Rights Division Special Litigation Section 950 Pennsylvania Avenue, NW PHB Room 5028 Washington, D.C. 20530 (202) 514-6255

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GERALD M. BL OP, #2753-45 Attorney for the Lake County Council 2115 W Lincoln Highway Merrillville, IN 4641 0 Phone: (219) 738-2400 Fax: (219) 738-2500 Email: gmb@bishop-1aw.com
Attorney forth ake County Sheriff 9111 Broadway, Ste GG P.O. Box 10607 Merrillville, IN 46411 Phone: (219) 738-2978 Fax: (219) 738-2818 email: jmklaw@sbcglobal.net

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&a ~ . ·~ ~~7 Em1e Di on

APPROVED and ADOPTED this 18'h day of August, 2010, by the LAKE COUNTY COMMISSIONERS.
Franc.es DuPey, President

APPROVED and ADOPTED this 18th day ofAugust, 2010, by the LAKE COUNTY SHERIFF.
~royRoy" Domingue ounty Sheriff

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FIRST COMPLIANCE REPORT LAKE COUNTY JAIL June 2011
A. MEDICAL CARE: Settlement Agreement Section III Part A.
1. LCJ shall provide adequate services to address the serious medical and mental health needs of all inmates.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
Adequate services are not being provided. The facility is beginning to revamp their medical program. On the day of our visit, the new Medical Director had yet to begin examining patients, put into place leadership changes, establish a table of organization (staff did not know who was in charge), develop policies and procedures, make available adequate space, or initiate key processes.
The Sheriff is recently elected and is committed to leading this program back to respectability. However, he has many key decisions to make. The Sheriff needs to decide whether to contract out services or manage them internally. MedStaff has been the contract medical vendor since 2007, supplying all medical staff. Dean Lichtenfeld, an RN, is the CEO of the organization and has been in that capacity for several months. The Director of Nursing for MedStaff was recently terminated and Susan Lass is the acting DON. No one in the organization has experience in correctional medical care. No leader in the organization has been in place for over a year. The organization lacks leadership and direction. Line staff do not know who is in charge and the program is drifting managed by line staff who have created their own processes. A Department of Justice Compliance Work Group has been established but this group has had only one meeting. This group consists of 7 different working groups. There is an Oversight Group and two other groups that work specifically on medical care; a Medical/Dental Work Group and a Quality Assurance and Quality Management Oversight Team.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Sheriff must solidify his leadership team and develop a table of organization which provides clear direction to line staff.
2. The Sheriff must organize his medical program so that all participants know who is in charge; know who is responsible for what; and know what the overall plan of action is. Someone must be in charge.
3. It should be made clear how the consultants are integrated into the organization. 4. The organization should consider supplementing his team with a leader with experience
in correctional medicine sufficient to assist the program toward compliance with this agreement.

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2. LCJ shall develop and implement medical care policies, procedures, and practices to address and guide all medical care and services at LCJ, including, but not limited to the following:
(1) access to medical care; (2) continuity of medication; (3) infection control; (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; (11) comprehensive health assessments; (12) mental health; (13) women's health; (14) quality management; and (15) emergent response.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
The existing state of policies is chaotic. MedStaff, the medical vendor, provided me with their policy manual which is dated January of 2009. This manual is not signed as reviewed by anyone. The manual is a boiler plate manual developed by mimicking the National Commission on Correctional Health Care standards. However, the manual does not reflect actual practice at the facility. For example, the manual states that there are quarterly administrative meetings when no such meetings take place. The manual stipulates 7 separate signatures of reviewer but none of these reviews were present in the manual provided to me. The manual calls for a Quality Improvement committee and monitoring which do not exist. The manual does not provide sufficient guidance on key items of this agreement as listed above.
One of the consultants provided a policy and procedure development guideline to be used by the Medical and Mental Health Programs in developing policies and procedures. According to the consultant, this document was not utilized by the medical and mental health vendors in development of policy or procedure. This document is a “how to” manual on policy development. Assuming that leadership can adequately implement this manual, it would be a useful guide in developing a policy for a given area.
In interviews with multiple line staff, none were aware of any existing policy or procedure pertinent to their area of service. Staff work by historical practice patterns and train each other in a variety of ways which do not appear to be standardized. A standardized procedural manual does not exist.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop key policies relevant to this agreement and listed above in item 2 of this Part A of the Settlement Agreement.
2. Consider soliciting additional expertise in correctional medical areas sufficient to guide policy development.
3. Intake Screening and Health Assessments.
a. LCJ shall develop and implement policies and procedures to ensure that adequate medical and mental health intake screenings and health assessments are provided to all inmates within 14 days. See also Section B. 2a-c of the Settlement Agreement (SA).
b. LCJ shall ensure that, upon admission to LCJ, Qualified Medical Staff utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:
(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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any of these items shall be referred for timely medical evaluation, as appropriate.
See also Section B. 2a-c of the Settlement Agreement (SA).
c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 days of his or her arrival at LCJ shall include a complete medical history, physical examination, mental health history, and current mental status examination. The physical examination shall be conducted by Qualified Medical Staff. 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 Medical Staff shall review prior records and update tests and examinations as needed. See also Section B.3a of the SA

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d. LCJ shall ensure that Qualified Medical Staff 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.
e. LCJ 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 24 hours of an inmate's arrival at LCJ, or sooner if medically necessary, Qualified Medical Staff shall decide whether to continue the same or comparable medication for serious medical needs. If the inmate's reported medication is discontinued or changed, a Qualified Medical Professional shall evaluate the inmate face-toface as soon as medically appropriate and document the reason for the change.
f. LCJ shall ensure that 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 Qualified Mental Health Professional. Staff will constantly observe such inmates until they are seen by a Qualified Mental Health Professional. Incoming inmates reporting these conditions will be housed in safe conditions unless and until a Mental Health Professional clears them for housing in a medical unit, segregation, or with the general population. See also Section C (Suicide Prevention) of the SA.
g. LCJ shall ensure that all inmates at risk for, or demonstrating signs and symptoms of drug and alcohol withdrawal are timely identified. LCJ shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.
h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.
i. LCJ shall ensure that correctional officers supervising newly arrived inmates 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 the intake health screening by Qualified Medical Staff. See also Section C.4 (Suicide Prevention Training).
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
Emergency Medical Technicians (“EMTs”) working in intake are not guided by a standardized policy or procedure. There is an intake policy in the MedStaff policy manual of 2009 but it is inadequate.

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EMTs perform screening. On several charts reviewed, EMTs missed major items of concern or failed to identify an issue as something that needed to be brought to the attention of medical staff. These screening evaluations are done in public areas without privacy which detracts from the accuracy of the evaluations. There is no symptom history of TB and no HIV history. The EMT staff refer to nurses anyone that they identify with a medical problem which results in a redundant evaluation. It would be better if Registered Nurses performed these screening evaluations in the first instance. There is no training of the EMT staff in how to screen and refer. When the EMT identifies a problem, they send a “TO DO” note electronically to nursing and the nurse will follow up. One midlevel provider reviews EMT evaluations but this is not specified in policy or procedure and is not consistently performed.
The purpose of the 14 day assessment is to evaluate the health status of persons coming into the jail. For persons with chronic illness or other medical conditions, the health status is an important first step in ensuring that the detainee has his or her medical condition correctly identified and correctly managed. This does not occur at Lake County Jail. The 14 day assessment is treated as a formality which must occur for all inmates by day 14 regardless of the medical condition of the detainee. Those with medical conditions should be seen earlier than 14 days depending on the severity and acuity of their condition. This is not occurring. Because providers are focusing on getting 14 day assessments done by day 14 they neglect attending to persons with serious medical conditions.
A health assessment report done by a medical assistant, showed all inmates who were incarcerated longer than 14 days but did not have a 14 day assessment. There were 27 overdue individuals. Patients are scheduled on day 8 of incarceration for their assessment. On the day of my visit, 263 inmates were in need of a 14 day assessment. Twenty people are scheduled daily (Monday through Friday) for the 14 day assessment but only about 8 are seen. Thus, most individuals coming into the jail fail to get a 14 day assessment. This includes individuals with serious chronic illness who may never see a physician for a status update of their illness. The system, therefore, fails to accomplish the major goal of this initial screening process – to capture and assess those with serious and/or chronic illnesses. At the assessment rate described above, the steady state of this system is that most individuals leave the jail before the 14 day assessment is finished.
EMTs ask questions about medication. The question regarding psychotropic medications is on the Admitting Medical Assessment Forms. If a person is on medication, the medic notifies a nurse who comes to see the patient. The nurse verifies with the community pharmacy that the patient is on medication and orders the medication in CorrectTek. Nurses are writing orders for medication. I was told that these orders are verbal orders but there is nothing in the medical record to verify that these are verbal orders. Physicians do not sign off on any of these orders. This has the appearance of nurses ordering medication. Daily, a list of medications is sent to In Touch, the pharmacy. They will send medication within 24 hours or the following day. A few dozen drugs are kept in the emergency drug storage. If inmates bring their own medication they are allowed to use it. This can be problematic if the nurse does not verify every pill. It would be better to not permit this practice. Nurses manage medication ordering until a physician sees the

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patient which may not occur for days or weeks. There is no evidence that physicians are involved in medication management during the first weeks of incarceration.
For detainees with drug or alcohol withdrawal issues, care is fragmented. When EMTs identify patients with drug or alcohol problems they write a “TO DO” referral to a nurse. One such referral I reviewed was not acted on by anyone. This can be a major patient safety issue. The EMT took a history that the detainee had delirium tremens (DTs) in the past. The detainee was not seen by anyone. Within a few days the detainee began acting bizarre on the unit and was seen by a mental health staff who had the detainee placed on the mental health unit. Within a day the inmate was hallucinating. The detainee was not referred for a medical examination by mental health staff. Within another day, the detainee developed seizures and lacerated his forehead. He was released from custody and sent to a local area hospital.
The existing acute alcohol withdrawal procedure which is established in the electronic record as an order, permits nurses to order scheduled drugs for treatment. This procedure should be reviewed and revised. The electronic version in the order section of the electronic record should be modified.
The screening information performed by EMTs is incorporated in the medical record. However on some charts reviewed the screening information was incompletely filled out. There is a process for PA or nurse review of the EMT work but this is not consistently performed.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Registered Nurses should perform intake screening. 2. The system should perform an acuity ranking system so that those with serious medical
problems are timely seen after intake screening. Providers should prioritize those detainees with serious medical conditions. 3. A standardized system of review of the intake evaluations should be put in place. 4. Privacy should be established for intake screening evaluations. 5. Standardized alcohol and opiate withdrawal procedures should be developed and synchronized with orders in the electronic record. These procedures should be approved by the Medical Director and should be consistent with standardized treatment of withdrawal syndromes. 6. Perform an audit regarding the medication verification process that will include the bridging order and referral processes.
4. Acute care.
a. LCJ shall provide adequate and timely acute care for inmates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will include timely medical appointments and follow-up medical treatment.
OVERALL COMPLIANCE RATING: NON COMPLIANCE

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ASSESSMENT:
I discussed operational procedures with Susan Lass, acting DON and Dean Lichtenfeld, the CEO of MedStaff. I also reviewed several medical records.
Inmates requiring acute care hospitalization are sent to local area hospitals: Pinnacle Hospital, South Lake Medical, or St. Anthony’s. Future plans call for an agreement with only South Lake Hospital. Either an ambulance or squad car is used to transport the patient. Due to the lack of physician coverage, almost all decisions to move patients to a hospital are made by a nurse in consultation with a physician. Patients who require hospitalization are occasionally released from custody just prior to admission to a hospital. This occurred with one patient during my visit. I was told that this happens more than occasionally. These patients should be tracked from a utilization and quality perspective.
Hospital arrangements appear adequate. Transport of patients to a hospital appears adequate. However, the management of seriously ill patients at the correctional facility is poor and this poor care results in excess and unnecessary hospitalization. As well, when patients return from acute care hospitalization, they are not evaluated by a practitioner, which results in interruptions in the care plan.
One example was a patient who had a bullet fragment removed and had sutures placed to close the wound. The inmate started putting in sick call requests because of an abscess on his buttock and to have the sutures removed. The sutures had been in place for over two weeks; at least one week longer than necessary. The detainee placed two sick call requests to address the abscess on his buttock but wasn’t seen. About ten days later a nurse saw the patient emergently and he was transferred to a hospital for treatment. Upon return from the hospital, the patient wasn’t ever seen by a physician even though a nurse ordered antibiotics upon return from the hospital.
A second patient had hypertension, an old stroke, cardiac arrhythmia and high blood cholesterol. An electrocardiogram was never done and though the physician saw the patient he wasn’t examined. He was seen on an emergent basis for cellulitis, a soft tissue infection, by a nurse and sent to the hospital.
Another patient was incarcerated with a history of asthma and sickle cell disease. The patient had severe sickle cell disease. A doctor saw the patient about a week after incarceration and the doctor did not examine the patient but did order lab tests. The lab tests were significantly abnormal and would have indicated that a transfusion was indicated but the test results weren’t reviewed for about two weeks. During the period when the lab test was not attended to, the inmate had difficulty breathing, which could have been related to his anemia. A nurse called the doctor at night and the doctor recommended admission. The inmate was admitted to a hospital but released from jail during the hospitalization.
The lack of provider evaluations of inmates with serious medical problems results in an unnecessary pattern of hospitalization for acute problems due to a lack of management of routine problems.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Provider time should be increased so that all patients with chronic illness are evaluated timely with a thorough evaluation as needed based on their condition.
2. All inmates returning from the hospital should be seen immediately upon return by a Registered Nurse. A physician appointment should occur at least within 72 hours of hospitalization. The physician should evaluate the status of the patient and ensure that the problem which resulted in hospitalization is stabilized.
3. The organization should track all off site hospitalization and emergency room visits to include: a. Patient name b. Housing unit c. Date of service d. Hospital patient was sent to e. Reason for transfer f. Diagnosis at the hospital g. Length of stay
4. The Medical Director should review this list monthly and evaluate whether there were preventable hospitalizations. This process should be used to identify problems with care management.
5. Chronic care.
a. LCJ shall develop and implement a written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.
b. LCJ shall adopt and implement appropriate written clinical practice guidelines for chronic and communicable diseases, such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, consistent with nationally accepted guidelines.
c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.
d. LCJ shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates' individual medical records.
e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions.
f. LCJ shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically

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appropriate care.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
There is an inadequate chronic illness policy and procedure. The 2009 policy manual of MedStaff does not address chronic care processes at the facility. A reasonable policy would include:
a. Directions for what needs to occur when a person is identified with chronic illness at intake.
b. An acuity ranking that determines the timeliness of evaluation by a physician after intake.
c. The interval visit schedule for various types of chronic illness. d. Directions for maintaining the problem list and for maintaining a chronic illness
roster. e. Reference to clinical practice guidelines that are used as the reference for managing
various common illnesses. f. Directions for staging degree of control and status and directions for interval follow
up based n the degree of control.
I was given sample copies of two clinical practice guidelines. Both of these were taken from the Federal Bureau of Prisons which is an organization of almost 200,000 inmates. The MRSA guideline alone is 48 pages. Using these guidelines would be acceptable but the guidelines would have to be modified so that the processes pertinent to the LCJ are included in the guideline and the items in the Federal guidelines which don’t apply to the jail are removed. The guideline given to me addresses inpatient treatment of MRSA but the LCJ does not have an inpatient unit. .
The medical program provided a roster of persons with chronic illness but it contained only 65 persons which is approximately 7% of the population. This is not credible. A second list was provided that included 162 names but this list contained conditions which were not chronic diseases such as constipation. Therefore, I could not verify that a complete, credible and accurate list of chronic illness patients exists. Staff agreed with me. I was told that the medical record software could produce such a list but this is not yet functional. The electronic record does have the capacity to document chronic illnesses in a problem list, but it is not consistently used. There should be standardized procedures for utilizing this function. Chronic illness is not tracked so there is no system to schedule persons with chronic illness for medical clinics to manage their illness. As a result, persons with chronic illness are randomly seen on an episodic basis which chart reviews demonstrate result in bad outcomes. There should be an electronic scheduling function within the electronic record.
The record has the ability to maintain records of treatment for chronic illness based on a review of the EMR. Specific chronic care notes, however, are rarely seen. Provider notes on persons with chronic illness do not always address chronic care issues. In one example, a patient on warfarin who had not had adequate management of his anticoagulation, presented to clinic for a

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pain control issue. Instead of intervening and managing the patient’s anticoagulation issues, the doctor only focused on the complaint. This type of episodic management reflects a lack of chronic disease management.
Patients are not scheduled for chronic illness clinic. Even when patients with chronic illness come to clinic for reasons other than their chronic illness, the providers do not update the status of the chronic illness. Medication management mostly occurs by nurses renewing expired medications; it does not appear that there is physician involvement. Persons on medication for chronic illness do not appear to have physician involvement regarding their medication management.
In reviewing charts the following problems were noted.
One inmate with significant emphysema, hypertension, and diabetes was only evaluated by a nurse. She was discharged about two weeks after incarceration without having seen a physician.
Another patient with asthma did not have a measure of her lung function (Peak Expiratory Flow rate). She was seen once and then not seen again for her chronic illness. She was seen two months after her first physician visit for an abscess but her chronic illness problems were not addressed.
Another patient was on a medication that is used for chronic illness but the EMT in intake did not identify a chronic illness. The patient’s medication (warfarin and prednisone) were noted and a nurse ordered the medication. Two weeks after incarceration the patient was seen for a rash but the chronic illness was not evaluated. A month later the patient was again seen for a rash and again the chronic illness was not address and the patient was left on the medication which has significant complications when not managed properly. Five weeks after incarceration a midlevel provider identified one of the chronic illnesses (a deep vein thrombosis). This accounted for the use of warfarin. Warfarin is an anticoagulant used to treat clots. The history of this person’s clot was not thoroughly identified and it is not clear that the patient needed the treatment. Because the degree of anticoagulation was not monitored adequately, the patient sustained a near life-threatening bleeding episode. The treatment, except for the potentially life threatening episode, was consistently subtherapeutic. Despite months in the jail the providers did not obtain therapeutic drug levels of the anticoagulant. The providers did not identify whether the patient even needed the anticoagulant. As well, the patient remained on a very high dose of steroids and the reason for using this medication was never identified. This episodic type care was inadequate.
A person with HIV disease, asthma and epilepsy had medication ordered by a nurse. He had come to the jail directly from a hospital but the reason for that hospitalization was not determined. Several of his medical conditions were not identified at the jail but were noted in the hospital record which does not appear to have been reviewed. The man complained of weight loss and difficulty swallowing but was not evaluated for AIDS related conditions. His medications were renewed remotely by nurses without adequate physician involvement. His HIV infection was never adequately evaluated during incarceration.

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Lastly, there is no place to manage patients who need skilled nursing care. There is no infirmary unit. Patients with disabilities or who have serious chronic illness are housed on the 4th floor of the jail. This unit is treated no differently than a general population part of the jail. Nurses do not have expedited access; instead they must search out an officer to gain access to detainees even if the detainee has significant problems. The fourth floor has no cells which can accommodate someone with a disability in line with the American for Disabilities Act. Lastly, patients with serious medical conditions on this floor are not specifically tracked or rounded on in an organized fashion.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Policy and procedure for chronic illness management must be developed. 2. Management of chronic illness should begin in intake with identification, acuity ranking
and appropriate referral to a provider. Nurses must not perform medication management. 3. The providers must use a standardized method of recording problems in the electronic
record which permits maintaining a roster of persons with chronic illness. 4. An electronic scheduling function should be available within the electronic record. In
lieu of this a manual system must be used that ensures adequate scheduling which can be tracked. 5. Physicians must manage chronic illness by seeing patients at appropriate intervals, renewing medication, and performing thorough evaluations pertinent to the chronic disease being managed. Nurses should not renew medications. 6. Lab and other testing (EKGs) should be performed as indicated by appropriate guidelines at indicated intervals. 7. Chronic illness guidelines need to be developed or obtained from other national guidelines. However, these must be modified to mesh with the program at the Lake County Jail. 8. A system of management of patients with disabilities and serious medical problems equivalent to infirmary care must be established. Such a system would include:
a. Admission by a physician b. Tracking of these 4th floor patients by name and diagnosis c. Acuity ranking of patients d. Defined interval evaluations by nursing and medical staff e. Rules for management of types of patients f. Rules for who can be admitted to the unit g. Discharge criteria h. Discharge only by a physician i. Complete access to physicians j. Adequate nursing coverage k. Physical space that accommodates ADA type patients l. A manual of care for nurses on the unit 9. Additional physician time needs to be added in order to see the volume of patients that exist. I would recommend a full time physician to start with and then to reassess whether all patients can be seen.
6. Treatment and Management of Communicable Disease.

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a. LCJ shall develop and implement adequate testing, monitoring, and treatment programs for management of communicable diseases, including tuberculosis ("TB"), skin infections, and sexually transmitted infections ("STIs").
b. LCJ shall develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
c. LCJ shall continue to test all inmates for TB upon booking at LCJ and follow up on test results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LCJ shall follow current CDC guidelines for management of inmates with TB infection, including providing prophylactic medication when medically appropriate. If directed by a physician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.
d. LCJ shall ensure that any negative pressure and ventilation systems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. LCJ shall document results of such testing.
e. LCJ shall develop and implement adequate guidelines to ensure that inmates receive appropriate wound care. Such guidelines will include precautions to limit the possible spread of Methicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.
f. LCJ shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
A Registered Medical Assistant performs all tuberculosis skin testing. A nurse practitioner is in charge of infectious disease surveillance but he was unavailable for the entire tour. The Registered Medical Assistant does not follow any written guidelines. There is no evidence of any active surveillance for tuberculosis, MRSA, or influenza. Staff are not certain what needs to be done and what would constitute an active surveillance program. MRSA statistics are maintained by one of the clerical staff based only on positive cultures which are presented to him

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by clinicians. MRSA rates, not unexpectedly, are reported as very low because of the way infection is reported.
One of the consultants provided me a Federal Bureau of Prison clinical practice guideline for MRSA and blood borne pathogen exposure management. Using other guidelines for the Lake County Jail will save time, but modifications must be made to adapt to conditions at the jail. Despite the attempt of the consultant to assist the organization of a policy on infection control, there are no policies or procedures for infection control for the jail. Lines of authority for infection control are not clear. It is not clear what role the physician assistant has in managing this program and it appears from the structure of the program that there is insufficient knowledge on what should be done to manage such a program.
The Registered Medical Assistant (“RMA”) has been doing TB screening for 15 years. The RMA places Mantoux skin tests during the work week. The process of screening is as follows. The RMA uses the custody database (Spillman) to identify all intakes (Monday through Friday). The RMA takes the list and finds the inmate and screens them Monday through Wednesday and again on Friday. If a skin test is positive, the detainee is given a mask and put in a separate cell. Proper isolation is not performed. If negative pressure isolation is not present in the jail, and the individual is suspicious for active disease the patient should be hospitalized. However, positive skin test inmates should be evaluated by a provider. Those who do not have symptoms suggestive of active disease need a timely x-ray and may not need isolation. For positive skin tests, an x-ray is ordered; mobile x-ray comes twice a week. While the patient is waiting for the x-ray the nurse practitioner or other midlevel talks to the patient through the window of the cell the same day or next day. The RMA thinks she has about 6-8 cases of positive PPD per month out of about 280 tested. This is a 2% positivity rate which would be unusual for this area.
Potentially contagious inmates are placed in a single cell; there is no negative pressure isolation. The patient is masked. No other isolation is done. This is not in keeping with national and Centers for Disease Control guidelines.
Guidelines for MRSA infection do not exist. One of the consultants provided me a 48 page Bureau of Prison MRSA guideline. It would be OK to use this with modification, but those modifications should be done. In any case, the guideline he gave me is not used by staff. The staff are working without any guideline to standardize care for MRSA.
A nurse practitioner maintains statistical data for infection control. However, he is not trained in surveillance techniques. There is no infection control nurse. It does not appear that there is physician oversight over this program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop an infection control plan that includes tuberculosis screening, MRSA management and influenza management. This plan should also include Occupational Health and Safety required blood borne pathogen practices and isolation procedures in the event of an airborne contagious disease event.
2. Develop treatment guidelines for MRSA and tuberculosis.

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3. Develop vaccination procedures for influenza. 4. Develop airborne isolation procedures consistent with Centers for Disease guidelines. 5. Assign a nurse to manage infection control issues. 6. Establish surveillance tracking of tuberculosis, skin test rates, conversion rates, employee
conversion rates, and MRSA rates, 7. Establish physician oversight over infection control issues.
7. Access to Health Care. a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.
b. LCJ shall ensure that the medical request ("sick call") process for inmates is adequate and provides inmates with adequate access to medical care. The sick call process shall include:
(1) written medical and mental health care slips available in English, Spanish, and other languages, as needed;
(2) a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week;
(3) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and
(4) opportunity for all inmates, irrespective of primary language, to access medical and mental health care.
c. LCJ shall ensure that the sick call process includes logging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation of the date and summary of each request for care, the date the inmate was seen, 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. LCJ shall document the reason for and disposition of the medical or mental health care request in the inmate's medical record.
d. LCJ shall develop and implement an effective system for screening medical requests within 24 hours of submission. LCJ shall ensure sick call requests are appropriately prioritized based upon the seriousness of the medical issue.
e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
f. LCJ shall ensure that there is an adequate number of correctional officers to escort inmates to and from medical units to ensure that inmates requiring treatment have timely access to appropriate medical care.
g. LCJ shall ensure that Qualified Medical Staff make daily rounds in the isolation

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areas to give inmates in isolation adequate opportunities to contact and discuss medical and mental health concerns with Qualified Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medical Staff will assess inmates for new clinical findings, such as deterioration of the inmate's condition.
h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care will be provided regardless of the inmate's ability to pay. No fee-for-service shall be required for certain conditions, including health screenings, emergency care, and/or the treatment and care of conditions affecting public health, e.g., Tuberculosis, MRSA, pregnancy, etc., particularly for indigent inmates who are not covered by a health insurance plan or policy.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
Inmates in the Lake County Jail do not have timely or adequate access to health care.
A Registered Medical Assistant (“RMA”) manages the sick call request scheduling process. The current version of the sick call slip is only in English. The form does not include mental health or dental items for inmates to check. Not all living units have a confidential collection box. On the units without a box, officers pick up the slips and hand them to nurses. The slips are picked up daily. Illiterate inmates get help from custody according to Ms. Smith. Inmates who speak other languages don’t fill out health service requests. I am not sure what happens to them.
There is no current system to log or track sick call requests. The program was attempting to be able to enter information into CorrectTek, the electronic records system, but this has not been done. There is no current system to provide a list of the inmates who placed sick call requests on any day. There are no nursing progress notes or face to face encounters documented for any of the sick call requests reviewed.
Nurses collect the slips and review the slips daily. The nurse identifies to the RMA (as documented on the slip), the date the slip was received, whatever assessment was done and what needs to be done. The nurses select those inmates who need to be seen. The nurse will go to the cell and do a quick assessment which may include vital signs. Nurses do not do sick call assessments in the clinic; only cell side. This is inappropriate; all face to face encounters should be performed in a clinical setting. Because of staffing, the nurse assigned to perform sick call requests sees only as many as she is able to see in the day. I was told that typically there are about 50 requests a day and the nurse only sees about 10. Many of the rest are scheduled for the provider but the provider is only able to see a fraction of this number. Because of custody movement issues and security counts, clinic hours are limited to 8:30 AM to 10:30 AM and 12:30 PM to 2:30 PM. This is unacceptable. Even if more providers and nurses were hired, there are insufficient clinic hours to see everyone who needs to be seen. This system prioritizes requests on a random basis and only evaluates a fraction of the requests daily. Finally, not all

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patients have access to be seen daily. The schedule of providers is such that it is impossible to schedule on a daily basis referrals from nurses who may need to be seen. This should be available at least five days a week.
The nurse who was performing sick call requests on the day of my visit estimated that about 15% of inmates get a cell side visit. About 10% don’t get seen because they leave or refuse. All others are scheduled to be seen in clinic. About 10 a day are scheduled to be seen in clinic. But these appointments compete with appointments for 14 day assessments and chronic illness visits. It is impossible to see the total volume of sick call requests, chronic illness visits and 14 day assessments in the allotted time provided by custody. Thus, nurses only see patients cell side for sick call which is an inappropriate clinic setting in which to see patients. The clinic itself is a large room with three side by side examination tables which are used simultaneously without privacy. Officers sit in the room near the inmate. There is no privacy. The room is cluttered with papers, boxes of supplies, etc., and is not orderly. This is an inappropriate setting to use as an examination room. Also, nurses should not be evaluating inmates cell side.
I was provided a list of protocols which I assume are used by nurses when evaluating health requests. These protocols assume that a diagnosis is made. For example, one protocol is for strep throat. This assumes that a nurse will make a diagnosis of streptococcal throat infection which the nurse is not licensed to do. As well, these protocols give license to the nurse to prescribe medications (standing orders) which is not a good practice and may be illegal.
Given the hours of clinic, it is apparent that there are insufficient officers to escort inmates for the various scheduled clinic visits. I was told that no shows to clinic are tracked but I was not provided information on this. There will need to be an increase in the movement officer staffing to ensure that inmates are escorted to clinic. Once in clinic there should be a written procedure for the conduct of officers in the clinic that ensures both safety and privacy. The numbers of no shows should be tracked and provided to the Sheriff on a regular basis.
Every shift, the segregation rounds consists of walking around the segregation areas to pass medication and ask if everyone is OK. This is not documented. Custody maintains a book that tracks who comes on the unit but the purpose of medical visits does not indicate whether this is for rounds or medication administration. There will need to be documentation of segregation rounds that indicates what occurred.
I was unable to evaluate the co-pay system. One of the Med Staff employees does the billing for the co-pay program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Sick call policy and procedure must be developed. 2. Secure collection boxes must be available on each living unit within the facility. 3. Sufficient staff should be available to evaluate all slips. 4. Nurses should triage all slips within 24 hours. 5. Emergent issues must be addressed immediately.

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6. Slips that include symptoms must include a nurse face to face evaluation in a clinical setting. This should occur no later than 72 hours based on the clinical issue.
7. A system of tracking requests should be maintained. A list of items was provided to MedStaff personnel.
8. A way to document a face to face evaluation by nursing should be established in the medical record that associates with the medical card in question.
9. The “Inmate Medical Card” should be revised to include: a. Mental health requests b. Dental requests c. A space to date the day the card was received by medical and the date triaged by a nurse d. A space for a nurse to write a brief triaging note. e. Typical complaint types
10. Metrics should be instituted in the Quality Improvement program to include: a. The number of requests picked up daily b. The number of slips triaged within 24 hours c. The number of slips with symptoms that had a nurse evaluation within 72 hours. d. The number of slips referred for provider evaluation.
11. A monthly nurse quality evaluation should include supervisory review of a select number of nurse evaluations to ensure adequate quality.
12. All nurse evaluations should include vital signs. 13. Nurse protocols for evaluations should be developed. These must be approved by the
Medical Director.
8. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates who receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimum, discharge instructions are obtained, appropriate Qualified Medical Staff reviews the information and documentation available from the visit, this review and the outside provider's documentation are recorded in the inmate's medical record, and appropriate follow-up is provided.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
When patients go out to a hospital or emergency room there is no standardized follow up evaluation except that they see a nurse. Nurses will order any new medication but there is no physician follow up at all. Physicians should order new medication and this should be documented in the electronic record. As well, physicians should see patients within 5 working days (sooner if clinically indicated) to evaluate the status of the patients who return from hospitals. A policy and procedure should be developed for this.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Upon return from the hospital or off-site consultation, all patients should go to a standard central location and be evaluated by a nurse and physician. If a physician is not present, the nurse should evaluate the patient and consult with a physician regarding any change in therapy. This discussion should be documented in the medical record.
2. The patient should be scheduled for a follow up physician visit to discuss and evaluate disease status.
3. A log of all off-site and hospital appointments should be maintained. 4. For quality purposes, the log should be evaluated monthly to assess whether follow up is
occurring as indicated.
9. Emergency Care.
a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health needs receive timely and appropriate care, including prompt referrals and transports for outside care when medically necessary.
b. LCJ shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
OVERALL COMPLIANCE STATUS: NOT APPLICABLE (Unable to review the relevant data during this assessment. Will review during the next site visit).
ASSESSMENT:
I was told by custody staff that CPR training of officers occurs but I was unable to document this.
Custody staff should all receive CPR training. In addition, the Medical Director should provide to officers a brief periodic training on recognition of serious medical conditions such as out of control diabetes, drug withdrawal syndromes, etc. As well, blood borne pathogen training should be provided by a nurse. This should occur regularly, at least annually. Training rosters should be maintained.
I was unable to verify that all officers had access to protective gear in the event of an emergency.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

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1. The Medical Director should develop a training module for custody staff to include serious medical conditions and blood borne pathogen issues.
2. Officers should be trained and their training should be verified in a tracking log. 3. At the next inspection protective gear for officers will be evaluated.
10. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical and mental health needs of inmates at LCJ.
b. LCJ shall develop and implement policies, procedures, and practices to ensure timely responses to orders for medications and laboratory tests. Such policies, procedures, and practices shall be periodically evaluated to ensure timely implementation of clinician orders.
c. LCJ shall ensure that medical and mental health records are centralized, complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out of LCJ for medical care. LCJ shall obtain records of care, reports, 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.
e. LCJ shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There is an electronic medical record but it is incompletely installed. Apparently, this software was not installed with participation of medical staff. Requirements were not established and needless to say this resulted in a less than adequate functional record. The electronic record lacks an interface with Spillman, the correctional database. As well, there are no interfaces with the laboratory or the pharmacy software. As a result, laboratory results are handled manually and are often not timely reviewed. I reviewed the folder in which these manual results are kept and in one chart I reviewed a lab indicating a serious medical problem wasn’t reviewed for weeks.
Medications are mostly ordered by nurses. There is no system in the electronic record that can document signature of a physician for a verbal order. There is also no interface with the

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pharmacy. I asked for a list of persons on medication and received a list of more than 2300 persons. This is more people than are in the jail. This indicated that the pharmacy does not know who is in the jail.
Many of the processes of the jail are not supported by medical record functionality. Typically, installation of a record is started by developing a list of requirements of the organization. These functional requirements are then built into and designed into the medical record. Interfaces with other software are developed and people are trained. None of these were accomplished with the installation of CorrectTek, the electronic record. Training was so poor that most staff train themselves and then train each other. As a result, the software is not used in a standardized manner.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The CorrectTek company should re-install the software starting with a requirements list and development of modules specific for processes in place at the facility. Training commensurate with the state of knowledge of the staff should occur in the go-live.
2. Interfaces with Spillman, the pharmacy software, and with the laboratory and any other key software should be put in place.
3. Staff dedicated to maintenance should be hired and training staff should be in place when new employees start work.
4. A system of reporting and tracking software issues should be instituted to ensure that software problems are solved.
5. A report line should be available to call in the event a software problem occurs. 6. A manual back up system should be in place in the event the software goes down.
Instructions in the event software crashes should be documented in a “down time procedure”.
11. Medication Administration.
a. LCJ shall ensure that inmates receive necessary medications in a timely manner.
b. LCJ shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. LCJ shall provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
c. LCJ shall ensure that medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. LCJ shall ensure that medication administration is performed by Qualified Nursing Staff who shall administer prescription medications on a directlyobserved basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications without

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a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.
e. When LCJ has advance notice of the discharge of inmates with serious medical or mental health needs, LCJ shall provide such inmates with at least a sevenday supply of appropriate prescription medication, unless a different amount is deemed medically appropriate, to serve as a bridge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. LCJ 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 LCJ. LCJ shall ensure that information about potential release or transfer of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a formal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications.
g. LCJ shall ensure that Qualified Medical Staff counsels all patients who refuse medication. See also Section B.4.b of the SA.
h. LCJ shall secure the medication room and discontinue allowing food to be stored in the medication refrigerator.
COMPLIANCE ASSESSMENT: NON COMPLIANCE
ASSESSMENT:
Whether individuals get their medication timely is not audited. An electronic Medication Administration Record is in place. The quality improvement committee should attempt to identify a way to obtain data from the record indicating time of prescription to time of delivery of medication.
There are only boiler plate policies. Nurses who administer medication told me that they are unaware of a policy or procedure for the administration of medication. The existing practice for initiating and renewing medication mostly depends on nursing staff to order medication. The degree of physician noninvolvement is staggering. It does not appear, based on documentation available, that physicians are involved at all in prescription of medication. Almost all medication is prescribed by verbal order; with nurses ordering medication. This is unacceptable.
Only LPNs or RNs are assigned to administer medication. The actual administration of medication appeared to be in accordance with the 5 rights and was hygienic. One exception is that nurses will give inmates a days worth of medication in their hand as unpackaged pills.

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Inmates are allowed to take this medication back to their tier and take it later. This process is in place for psychotropic medications and is typically an unacceptable practice. Credential data was available and maintained by MedStaff indicating up to date licensure of nurses. Renewal of medication is supposed to be done in clinic. All prescriptions have an automatic “pop up” which shows to providers a certain time period before expiration. When a physician or nurse orders a medication the order shows up in the eMAR. Because there is no interface with pharmacy, the nurse obtains a list of medication orders and faxes the list of medication of all new orders daily to the pharmacy. Verification can then be done there. I was told that the pharmacy tracks all medication; but this information is not current because the pharmacy is not interfaced with CorrectTek. All medications except inhalers are administered daily dose by dose.
There is no written procedure for administering medication, but the current practice for “uncomplicated” patients is that the patient is given a whole days supply in the morning in the existing package. The inmates who are uncomplicated is determined on a case by case basis apparently by nursing staff. No direction is provided by the Medical Director. A “split and watch” system consists of actually watching inmates ingest their medication. Many more patients should be on a watch-take basis, particularly for psychotropic medications. The facility has almost no keep on person program with the exception of inhalers. This would be a labor saving system.
Upon discharge from jail patients get 7 days of medication if the nurse knows a patient is leaving and if the patient presents to nursing. Practically, I found no way to verify whether this occurs as this activity is not documented or tracked. Nurses don’t always know people are leaving. When people leave to prison, the nurses get variable notice. When they are timely notified they prepare a medication list. If nurses are sent a release from the prison, the jail will send a copy of the record. HIPPA does not require patient consent when a jail provides confidential medical information to a prison. The medication packaging received from the pharmacy is acceptable. It takes about two hours a week to sort weekly cycle fill medication from the pharmacy. This is acceptable.
There is no formal P & T committee.
For people who refuse medication, there is no policy or procedure for what should happen. Every nurse is left to determine their own procedure for what to do if an inmate refuses medication. For refusals, some nurses send an electronic message to the provider. The provider can send a message back to the nurse but if that nurse is on vacation the directions from the provider may be lost until the nurse returns. This process should be standardized and documented in a policy and procedure.
Carts are left in a medical administration area which is similar to a lobby. Controlled substances are in a locked box within a locked medication cart. However inmates and civilian staff do walk amidst these carts. These carts should be stored in a secured area to which inmates do not have access. Medication is stored in multiple areas including: intake, in carts, and in medication rooms and in the emergency drug kit (EDK) room. The EDK room has a locked box for holding personal control substances that inmates bring in with them. Scheduled drugs come in patient specific 7 day allotments. All other drugs also come in 7 day increments. There are significant

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returns to pharmacy because inmates leave before completing taking all of their medication. The fact that so many returns to pharmacy occur is testament of the failure of delivering a 7 day supply of medication to patients who leave the facility. If patients were given a 7 day supply of medication upon leaving, there would be nothing to return to pharmacy. No one specifically is responsible for the med room. The medication room was not orderly. Some medication was stored on the floor which is unacceptable. The room was cluttered and not particularly clean.

RECOMMENDATION FOR THE NEXT 6 MONTHS:

1. Physicians must prescribe medication; not nurses. It must be obvious that this is occurring. Documentation of verbal orders must occur so it is obvious in the record that physicians are prescribing medication.
2. An interface with pharmacy should be established. 3. The quality committee should develop a mechanism to establish the average time from
prescription to delivery of medication to the patient. 4. Policies and procedures must be developed for medication administration and storage of
medication. Staff must receive regular training on these policies and procedures. 5. The Medical Director must establish what medication must be given dose by dose and
what can be given to the patient to take themselves. If medication is given to an inmate to take later, it must be in packaging by pharmacy. 6. Medication administration must be standardized. 7. The procedure for handling refusals of medication must be standardized and developed into policy and procedure. 8. Storage of medication carts should be in a secured area, away from civilians and inmates. 9. The medications rooms should be cleaned.

12.

Medical Facilities.

a. LCJ shall ensure that sufficient clinical space is available to provide inmates with adequate medical care services including:

(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric
and pregnant inmates).

b. LCJ shall ensure that medical areas are adequately cleaned and maintained, including installation of adequate lighting in medical exam rooms. LCJ shall ensure that hand washing stations in medical areas are fully equipped, operational and accessible.

c. LCJ shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and sharp medical tools) and hazardous waste.

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d. LCJ shall provide for inmates' reasonable privacy in medical care, and maintain confidentiality of inmates' medical status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT: The area for medical and mental health screening in intake is inadequate. Privacy does not exist. I watched intake on two inmates. There was no privacy at all. The EMTs had to move twice to various areas in an attempt to obtain privacy which was not ultimately obtained. Officers stand nearby listening to intake evaluations. I witnessed up to six officers joking and talking loudly within a few feet of the EMT who was trying to conduct a confidential interview. I don’t see how under these circumstances that a confidential interview can occur. Intake evaluations should occur in a private clinical setting with an examination table, light, and sufficient equipment. This does not now occur.
There is a single examination room for the entire jail. This room consists of a large room with side by side examination tables. Officers congregate in this room and sit in close proximity to where physicians are evaluating inmates. The room is cluttered, equipment is not close by, and there is no privacy. Given the number of evaluations necessary to accomplish in the jail, this is inadequate space. For each provider expected to be conducting evaluations there should be a clinic examination room of approximately 100-120 square feet. Each room should have an electronic record terminal, an examination table with unfettered access so that an examiner can walk around the table, easily accessible oto-ophtalmoscope, a sink to wash hands, accessible blood pressure cuffs and other necessary equipment. I estimate that at least 6 examination rooms are necessary.
Sick call evaluations are occurring cell-side. These are not private examinations. In aggregate neither sick call, chronic illness, intake, nor primary care physician visits occur in privacy in an adequate room.
There is no infirmary in the jail. Therefore, housing for inmates with disabilities and for those with special medical needs does not exist. The Medical Director should confer with the Sheriff and consider options for how these patients can be safely maintained in appropriate housing that accommodates their medical or mental health condition.
RECOMMEDNATIONS FOR THE NEXT 6 MONTHS:
1. An evaluation room for medical and mental health intake evaluations must be established which permits for both security and privacy concerns.
2. Adequate clinical examination rooms need to be built for sick call request evaluations by nurses and for routine clinic examinations by providers.
3. Develop a plan for medical and mental health infirmary care housing.
13. Specialty Care.

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a. LCJ shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at LCJ shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ 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 Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ 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, the reason for any missed or delayed appointments, and information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmates are provided adequate pre-natal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
In discussions with providers, it did not appear that visits to specialty clinics are timely. One example was a current inmate who had a potential threatened abortion for whom the provider could not get an appointment. Movement officers are not readily available so transportation is not based on need of the inmate but on the availability of an officer. This is not tracked so the exact situation is not known.
Inmates who are waiting for outside appointments that are delayed are not scheduled routinely to be seen by providers. It is uncommon for providers to see patients either before or after their appointment. This is due to lack of provider time.
Tracking of specialty appointments is performed. I did not verify whether tracking is specifically in accordance with the agreement.
Pregnancy care is unacceptable. There is a contract obstetrician but it is difficult to get an appointment even for problematic cases. There is no policy or procedure delineating care of the pregnant woman. Currently, pregnant women are placed on a special diet but there is no special housing provided. Providers do not routinely see a pregnant woman. Given that it is difficult to get appointments with the obstetrician, a pregnant woman may not see a qualified provider for weeks. Labs done at the obstetrician are not in the medical record at the facility so the providers

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at the facility will not know if the pregnancy is complicated or if there is something they need to be aware of. I was told that typically, pregnant women leave the jail before being seen. This is both a liability and a patient safety issue and should be corrected.
For one chart I reviewed, the pregnant inmate had a medical condition complicating her pregnancy and her appointment was so late that she developed a problem and had to be sent to a hospital before her appointment occurred. Her medical condition may cause a problem with her in utero fetus possibly causing fetal abnormalities.
Another chart reviewed was for a pregnant woman who had asthma complicating her pregnancy. She had not been seen for her asthma even though asthma can potentially be problematic in pregnancy. An appointment for the obstetrician was ordered on April 20 but was not scheduled until late in May. Pregnant women should be seen within a week of incarceration.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Specialty appointments should be tracked and reviewed by the Quality Improvement Program. The time from provider order to the appointment should be tracked and reviewed for appropriateness by the Medical Director.
2. Sufficient officer staffing should be assigned to transport patients for scheduled appointments.
3. Persons who fail to go to a scheduled appointment should be tracked and the reason for the missed appointment should be provided. This information should be provided to the Sheriff on a regular basis.
4. Pregnant females should be evaluated by an obstetrician within a week of incarceration. Prenatal lab tests can be performed routinely upon incarceration so that they will be available to the obstetrician and primary care providers at the facility.
5. Information from the obstetrician should be exchanged with the medical staff at the jail and scanned into the medical record.
6. Someone on site should be capable of performing a routine pregnancy visit for pregnant females so that care can be managed along with the obstetrician.
14. Staffing, Training and Supervision.
a. LCJ shall ensure that its health care structure is organized with clear lines of authority for its operations to ensure adequate supervision of the system's health care providers.
b. LCJ shall maintain sufficient staffing levels of Qualified Medical Staff and Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs. See also Section B.1 of the SA.
c. LCJ shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious medical and mental health needs of inmates. All such staff shall receive documented orientation and inservice training on relevant topics, including identification of inmates in need

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of immediate or chronic care, suicide prevention, and identification and care of inmates with mental illness. LCJ shall ensure that all other medical and mental health staff receive adequate training to properly implement the provisions of this Agreement. See also Section C.4 (Suicide Prevention Training) of the SA.
d. LCJ shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.
e. LCJ shall ensure that all persons providing medical or mental health treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health staff have current, valid, and unrestricted professional licenses.
f. LCJ shall ensure that correctional officers are adequately trained in identification, timely referral, and proper supervision of inmates with serious medical needs. LCJ shall ensure that correctional officers are trained to understand and identify the signs and symptoms of drug and alcohol withdrawal and to recognize and respond to other medical urgencies.
g. LCJ shall ensure that correctional officers receive initial and periodic training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); recognition of signs and symptoms evidencing a response to trauma; appropriately responding to mental illness; proper supervision of inmates suffering from mental illness; and the appropriate use of force for inmates who suffer from mental illness. Such training shall be conducted by a Qualified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual. See also Section C.4 of the SA.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
The Table of Organization and lines of authority are not clear now. This program is evolving and isn’t firmly established. Dr. Farley is now the Medical Director but hasn’t yet seen patients. The lines of authority need to be clarified to line staff who are unaware of who is in charge. A town hall type meeting would be useful at this juncture.
The staffing levels have not been determined by functional need. The existing staff level was determined in 2006. It was based on a mutual agreement between Dr. Gutierrez, a consultant to the County and the owner of MedStaff and on what the County Commission could afford. The staffing matrix was based on historical staffing not on the functional need of the facility. The original matrix was for 900 hours of staff time and has been raised to 1176 hours since then. Everyone I spoke with from management to line staff agreed that there is insufficient staffing for the functional needs of this program. Existing statistical information may not be totally accurate; nevertheless, it does point to a need for more staff. There are about 1200 intakes a month.

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Typically 30% will have some medical condition meaning that there are about 360 chronic illness or urgent care visits that should follow from intake. All 1200 should have a 14 day assessment. There are about 1200 medical card evaluations a month. Discounting chronic illness visits this results in approximately 1200 nursing evaluations and about 1600 provider visits a month. More Registered Nurse and provider hours are indicated. Better statistical data could be obtained for functional requirements.
Actual staffing levels were reviewed. They are inadequate. The current matrix calls for 8.4 FTE of LPN coverage; 2.4 FTE of RN coverage; 20 hour of physician coverage; and 1.6 FTE of mid level provider coverage. This is inadequate coverage.
There is no fixed orientation programs except to assign staff to various units and demonstrate to them current practice. No policy review occurs because no functional policies exist. Training is non existent, including training for the electronic medical record.
The current Medical Director has just started. However, there has been no physician oversight over this program. In the past, physicians were onsite only 4 hours a week. As a result, many standing orders were in place and nurses were basically allowed to practice and even order medication without physician supervision.
Nurses have licensure tracked by MedStaff. There was no credentialing process for providers. This should include credentialing similar to what is seen in a hospital. Mid Level providers should have their collaborating physician or supervising physician noted in their credential packet. All physician licenses and training should be evident in the credential packet.
Training of officers did occur in the past for certain mental health issues but I could not verify that this is occurring for medical items in the agreement. Training in accordance with terms of this agreement should be provided and the list of officers who received the training should be tracked.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A table of organization and organizational structure needs to be put into place as soon as possible.
2. The organizational structure and leadership structure must be communicated to all staff. I recommend a town hall format for this.
3. A proper orientation program should be put into place for all employees. This should include orientation to policies and procedures, security rules, and training necessary for functional competency (electronic record training, OSHA training, etc.)
4. The Medical Director must establish clinical authority and clinical supervision over the program. Mid-level providers must be supervised. Nurses must not be allowed to practice with standing orders with few exceptions.
5. A staffing analysis must be performed. This should be performed after policies and procedures are complete as the procedures will determine the functional requirements (and therefore staffing levels) of the program.
6. Provider credentialing must be put into place.

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7. Officer training must be tracked including name of officer, dates training occurred, and type of training given.
15. Dental Care.
a. LCJ shall ensure that inmates receive adequate dental care, and follow up. Such care should be provided in a timely manner. Dental care shall not be limited to extractions.
b. LCJ shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
The dentist only comes on Fridays for about 4 hours. There was no one to interview who could inform me of dental matters. The waiting time to see a dentist was about 4 weeks. Typically, in correctional facilities, one FTE dentist is required for every 800-1000 patients. This is not a hard and fast rule. I will need to verify dental statistics at the next visit and will need to speak with the dentist.
RECOMMENDATIONS FOR THE NEXT SIX MONTHS:
1. Dental requests must be tracked in a manner similar to health service requests. 2. Patients with dental pain should not exceed a week in waiting. 3. Dental complaints with pain or infection must be evaluated by medical staff pending an
appointment with the dentist.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and related medical data, for every inmate who dies while in the custody of LCJ or under medical supervision directly from the custody of LCJ.
b. LCJ 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 LCJ personnel and shall seek to determine whether there was a pattern of symptoms that might have resulted in earlier diagnosis and intervention. Mortality and morbidity reviews shall occur within 30 days of the incident or death, and shall be revisited when the final autopsy results are available. At a minimum, the mortality and morbidity reviews shall include:

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(1) critical review and analysis of the circumstances surrounding the incident;
(2) critical review of the procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental health services/reports involving the
victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures.
c. LCJ shall address any problems identified during mortality reviews through timely training, policy revision, and any other appropriate measures.
OVERALL COMPLIANCE RATING: NON COMPLIANCE
ASSESSMENT:
There has been one recent death. I could not verify that an autopsy had occurred. I was told that there is no mortality review and no mortality review committee.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A mortality review committee should be established as part of the Quality Improvement Committee.
2. Custody, mental health and medical should participate in these reviews. 3. The review should result in a document that gives recommendations for improving
aspects of care that were deficient as identified in the mortality review.
B. MENTAL HEALTH CARE: Settlement Agreement Part III Section B
1. LCJ shall provide adequate services to address the serious mental health needs of all inmates, consistent with generally accepted correctional standards of care, including sufficient staffing to meet the demands for timely access to an appropriate mental health professional, to ensure qualified mental health staff perform intake mental health screenings and evaluations, and to perform comprehensive assessments and comprehensive multidisciplinary treatment planning. See Section III. A.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Currently, there are only two (2) qualified mental health professionals (QMHP) working within the LCJ. One is a masters-level, licensed clinician, the other, a part-time psychiatrist whose hours were recently raised to 16 hours per week.

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In February 2011, Edgewater Systems (the mental health provider) was authorized to hire 6 additional QMHP staff that could be licensed either inside or outside the state of Indiana. As of April 2011, Edgewater has still had difficulty recruiting QMHP staff and, therefore, was tentatively given permission to increase the salaries of these new positions while reducing the number of additional QMHP staff to five (5). One of these QMHP positions will be designated as the Clinical Supervisor for the mental health program and be directly responsible for providing clinical supervisor to all mental health staff (with the exception of the psychiatrist). Edgewater has given the County assurances that all QMHP positions will be completely filled by June 2011.
In addition, beginning in March 2011, Edgewater hired seven (7) “residential technicians” (RTs) to provide primary observation of inmates on suicide precautions and/or mental health observation on the 4th floor.
Finally, Edgewater currently employs three (3) “crisis intervention specialists” (CISs) at the LCJ that fit the DOJ settlement agreement’s definition of Qualified Mental Health Staff. These CIS staff currently work in the booking area and conduct intake mental health screening (see Provision B.2.c). There are also two (2) other QMHS, one of which is the Administrative Mental Health Manager, and the other staff works on the 4th floor in a variety of roles.
In sum, as of April 25, 2011, the current mental health staffing at the Lake County Jail is as follows:
 2 QMHPs (including .4 FTE psychiatrist)  5 QMHPS (unfilled, including clinical supervisor)  7 Residential Technicians  3 Crisis Intervention Specialists  2 QMHS
In conclusion, current QMHP staffing is woefully inadequate to fulfill the requirements if this provision but the County is hopeful that these five (5) new QMHP positions will be filled by June 2011.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Fill the vacant positions.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR NEXT TOUR:
1. If the positions are not filled, provide relevant information re: recruitment efforts to fill the positions.
2. Timely and Appropriate Evaluation of Inmates.
a. LCJ shall develop and implement policies and procedures to provide adequate screening to properly identify and assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.

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OVERALL COMPLIANCE RATING: NON- COMPLIANCE
ASSESSMENT:
Edgewater Systems previously developed a Health Services Division-Lake County Jail-Policy and Procedure Manual, last revised in June 2010 that included many policies and procedures addressing National Commission on Correctional Health Care standards. Some of mental health policies include mental health screening and mental health evaluation; health evaluation of inmates of segregation; mental health services; suicide prevention; medical restraints and therapeutic seclusion; and forced psychotropic medication.
A review of the Edgewater Manual determined that many of these policies and procedures will need to be substantially rewritten in order to be in compliance with this DOJ Settlement Agreement, and incorporated into the Lake County Jail policy manual. The suicide prevention policy has been substantially revised and scheduled to be implemented in June 2011. It should be noted that Med-Staff, Inc. (the medical provider) previously developed a Health Services Division-Lake County Jail-Policy and Procedure Manual, last revised in January 2009 that included many policies and procedures addressing National Commission on Correctional Health Care standards. This document will not be utilized in the development of mental health policies and procedures for the LCJ.
In general, policies and procedures are either missing or outdated. Mental health policies and procedures should include the following topic areas:
1. Mission and goal 2. Administrative structure 3. Staffing (i.e., job descriptions, credentials, and privileging) 4. Reliable and valid methods for identifying inmates with severe mental illnesses (i.e.,
receiving screening, intake mental health screening, mental health evaluations) 5. Treatment programs available 6. Involuntary treatment including the use of seclusion, restraints, forced medications,
and involuntary hospitalization 7. Other medicolegal issues including informed consent and the right to refuse treatment 8. Limits of confidentiality during diagnostic and/or treatment sessions with pertinent
exceptions described 9. Mental health record requirements 10. Quality assurance and/or improvement plan 11. Training of mental health staff regarding correctional and/or security issues 12. Formal training of correctional staff regarding mental health issues 13. Research protocols
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop/revise policies and procedures as summarized above.
b. LCJ shall ensure that the intake health screening process referred to in Section

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III.A.2 includes a mental health screening, which shall be incorporated into the inmate's medical records. LCJ shall ensure timely access to a Qualified Mental Health Professional when presenting symptoms of mental illness require such care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Both the medical and mental health/suicide risk screening processes are automated and intake staff generates documentation that goes directly into CorrecTek, the electronic medical record. However, given current mental health staffing levels, there is not always timely access to a QMHP upon referral from intake. See Section B.2.c below. A practice is currently in place relevant to the mental health intake screening although a policy and procedure has not yet been developed. Due to staffing allocation issues, such screening is reportedly completed within 24 hours by a crisis prevention specialist (CIS). However, this process has not yet been audited.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedure. 2. Following implementation, audit the process.
c. LCJ shall ensure that the mental health intake screening process includes inquiry regarding:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or close
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency,
or similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The County has an intake screening process for the identification of inmates with mental illness and/or at risk for suicide, but the process is in need of corrective action. All newly admitted inmates are screened at booking by an Emergency Medical Technician (EMT) utilizing a Medical History and Screening form. Data from the form is directly entered into CorrecTek. EMT personnel are on-site in the Lake County Jail 24/7. In addition, all newly admitted inmates

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were previously screened at booking by a Crisis Intervention Specialist (CIS) utilizing a Mental Health Evaluation form. Data from this form was entered directly into CorrecTek. CIS personnel are on-site 24/7, with the exception of Sunday. In the absence of CIS staff on Sundays, mental health intake screening is delayed until the following morning. The County is aware that this practice is problematic and potentially dangerous, and working toward a corrective action.
In addition, the Mental Health Evaluation form contained many, but not all, of the nine (9) items listed above in this Provision. CIS personnel were previously directed that when an inmate answered affirmatively to any of the three suicide risk-related questions, they were to then complete a separate 17- item Suicide Assessment form. In an effort to streamline the process and ensure that all nine of the above items are adequately covered during the intake screening process, the County has introduced a new Mental Health/ Suicide Risk Intake Screening Form that includes 17 areas of inquiry, observation of mental status, and a disposition section. The new form was recently introduced during the week of April 18, 2011. CIS will now be responsible to check the alert screen of CorrecTek in determining whether the newly admitted inmate was a suicide risk during a previous LCJ confinement.
Although appropriate intake screening instruments are in place, corresponding policies and procedures need to be developed and/or revised. The County will work with either Med-Staff or Edgewater to ensure that the new Mental Health/ Suicide Risk Intake Screening Form is provided to newly admitted inmates on Sundays.
Finally, the drug and alcohol withdrawal history should be obtained via the medical history and screening intake form performed by the EMTs. However, this form needs to be revised to include such a history.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. As in Section B.2a of the SA. 2. Revise the medical history and screening intake form as above and include the drug
and alcohol withdrawal history.
3. Assessment and Treatment.
a. LCJ shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, or who is otherwise referred for mental health services, receives a comprehensive mental status evaluation in a timely manner from a Qualified Mental Health Professional (immediate for emergent issues, within 24 hours of referral for an expedited comprehensive evaluation, or 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 Qualified Mental Health Staff find a serious mental illness, they shall refer the inmate for appropriate treatment. LCJ shall review available information regarding any diagnosis made by the inmate's community

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or hospital treatment provider, and shall account for the inmate's psychiatric history as a part of the assessment. LCJ shall adequately document the comprehensive mental status evaluation in the inmate's medical record.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT: Given current QMHP staff levels, compliance with this Provision remains problematic. Inmates are not always provided with timely mental health evaluations and the above required three-level response of immediate, within 24 hours, and 72 hours is not being met. Although the psychiatrist had previously developed a Psychiatric Evaluation form that is consistent with the Settlement Agreement’s requirement of a mental health evaluation, the form has not been consistently utilized, particularly by the other QMHP staff member. Furthermore, the current vacancies result in lack of compliance with the relevant timeframes and the lack of the relevant policy and procedure contributes to inconsistent.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedure. 2. Following implementation, audit the process.
b. LCJ shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate referrals for specialty care and regularly scheduled visits with Qualified Mental Health Professionals.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Although the County and its consultants have not had an opportunity to verify through an auditing review as to whether identified inmates are receiving timely and appropriate referrals for specialty care, given current QMHP staff levels, compliance with this Provision remains problematic.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedure.
c. LCJ shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:

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Mental health clinicians are not currently developing treatment plans that adequately address inmates’ mental health needs.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the policy and procedure relevant to treatment plans.
d. LCJ shall provide for an inmate's reasonable privacy in mental health care, and maintain confidentiality of inmates' mental health status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
The County is aware that privacy and confidentiality is problematic within the Lake County Jail, particularly within the booking area during the intake screening process, and on the 4th floor when mental health staff are assessing inmates on suicide precautions. The County is currently looking at different options to reconfigure the booking area to allow both EMT and CIS staff sufficient privacy for conducting confidential intake screenings to newly admitted inmates. With regard to the 4th floor medical/mental health unit, current practice is for mental health staff to typically conduct “cell-front” assessments of inmates on suicide precautions and/or mental health observation status. The County acknowledges that this practice is problematic with the issues of privacy and confidentiality, and has identified visiting booths on the 4th floor that can safely be utilized for the assessment of inmates by mental health staff. Unless contraindicated by security concerns, mental health staff will be encouraged to utilize these rooms on a regular basis.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedure regarding privacy of clinical contacts.
e. LCJ shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see such inmates in a timely manner.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As of February 2011, on-site psychiatric coverage was increased to 16 hours per week. On-call psychiatric service is also provided as needed. It was reported that there were currently 100 to 165 inmates receiving psychotropic medications at the LCJ. The lack of an accurate or consistent number is concerning for many reasons, including need assessment purposes. It is extremely likely that 16 hours per week of on-site psychiatric coverage is inadequate for the needs of the jail population.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop an accurate management information system relevant to the mental health caseload at the LCJ.
2. Provide accurate statistics relevant to inmates on the mental health caseload at LCJ.
f. LCJ shall ensure timely and appropriate therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate space for treatment, adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Given current QMHP staff levels, compliance with this provision remains problematic. To date, there is little, if any, therapy and counseling occurring, or at a minimum, that which is adequately documented. There is not an adequate array of structured therapeutic programming.
The County and Edgewater have renovated several areas on the 4th floor for adequate office space for existing and anticipated new mental health staff. Most housing units already have existing space adequate for group treatment.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Fill the remaining QMHP vacancies. 2. Provide information relevant to treatment modalities being provided to inmates and
how many inmates are receiving such treatments.
g. LCJ shall ensure mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluated by a Qualified Mental Health Professional to determine the inmate's mental health status, which shall include an assessment of the potential effect of segregation on the inmate's mental health. During these regular evaluations, LCJ shall evaluate whether continued segregation is appropriate for that inmate, considering the assessment of the Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE

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ASSESSMENT:
Given current QMHP staff levels and deficient practices, compliance with this Provision remains very problematic. Currently, the Administrative Mental Health Manager conducts weekly rounds in segregation, and documents interaction with inmates on the mental health caseload on a Mental Health Rounds Form in CorrecTek, but this individual is not a QMHP. In addition, the County and its consultants have not had an opportunity to verify through an auditing review as to whether all inmates, or simply those on the mental health caseload, are being seen during rounds. Further, medical staff conduct regular rounds in segregation to dispense medication, but only interact with those inmates that are scheduled to receive medication. Reportedly, inmates scheduled to see the psychiatrist, but who are housed in segregation, will not be seen until after they have been returned to a non-segregation housing unit. Finally, mental health staff are not routinely notified (and/or receive timely notification) when an inmate on their caseload has been transported to segregation, and are not involved in disciplinary hearings. Mental health staff reported that it was common for the correctional officers to not escort segregation inmates for clinical appointments due to their segregation status. It was unclear whether this was a staffing allocation issue or a security regulation or practice. Not surprisingly, mental health staff are not involved in determining if an inmate’s disciplinary sanction might in any way be mitigated by their mental illness. These are all problematic areas that need attention.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Remedy the above situation.
h. LCJ 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. Each clinician shall have ready access to a current log listing any prescribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and accurate information regarding any medication changes ordered in at least the past year.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The Administrative Mental Health Manager maintains a listing of all inmates currently in the LCJ that are receiving mental health services, i.e. a mental health caseload. The County and its consultants have not had an opportunity to verify through an auditing review the accuracy of the mental health caseload. CorrecTek, the electronic medical record, should reflect each inmate’s psychotropic medication and current dosages, but again, this process has not been audited.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

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1. Verify through an auditing review the accuracy of the mental health caseload.
i. LCJ shall ensure that a Qualified Mental Health Professional conducts an in-person evaluation of an inmate prior to a medicallyordered seclusion or restraint, or as soon thereafter as possible. Patients placed in medically-ordered seclusion or restraints shall be evaluated on an on-going basis for physical and mental deterioration. Seclusion or restraint orders should include sufficient criteria for release.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
The LCJ does not have a written policy or adequate practices regarding the seclusion of inmates with mental illness. LCJ’s mental health provider, Edgewater’s “medical restraints and therapeutic seclusion” policy does not address seclusion. In practice, inmates with mental illness that are seemingly in need of seclusion are housed on the 4th floor medical/mental health unit under the cryptic description of “caution,” “observation,” or “1096.” There are no current written policies or directives that identify the behavior for which these identifications apply, nor criteria for admission/discharge from these statuses. Obviously, this is problematic and needs corrective action.
With regard to the use of restraint, although the current practice is that inmates in need of medical restraints are placed on a restraint bed on the 4th floor medical/mental health unit. Both LCJ’s medical provider, Med-Staff and Edgewater have written policies regarding the use of restraint. However; both are in need of revision. For example, neither policy addresses the specific staff member (corrections, medical, or mental health) who is responsible for providing observation of the inmate (in addition to CCTV), and the Edgewater policy fails to even mention any responsibility of QMHP staff in the process.
New policies are in the process of being drafted to eliminate inappropriate seclusion terms (i.e., “caution,” “observation,” or “1096”), and establish specific criteria and guidelines for seclusion. I reviewed a draft restraint policy and procedure with LCJ’s mental health consultant, Mr. Hayes, and made specific recommendations regarding relevant timeframes and credentials of clinicians authorized to order restraints and/or perform relevant need for restraints assessments. I also provided a resource document relevant to the use of restraints in a correctional facility published by the American Psychiatric Association to Mr. Hayes.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement a policy and procedure regarding the use of restraints/seclusion for mental health purposes.
2. Following implementation, audit the process.

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j. LCJ shall ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among inmates. Crisis services shall not be limited to administrative segregation or observation status. Inmates shall have access to appropriate licensed in-patient psychiatric care, when clinically appropriate.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Med-Staff and Edgewater do not have adequate policies regarding psychiatric emergencies. Access to inpatient psychiatric hospitalization for clinical purposes appears to not be available.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement a relevant policy and procedure regarding crisis services. 2. Remedy the lack of access to an inpatient psychiatric hospitalization for clinical
purposes. 3. A summary regarding efforts to remedy the lack of access to an inpatient psychiatric
hospitalization for clinical purposes.
4. Psychotherapeutic Medication Administration
a. LCJ shall ensure that psychotherapeutic medication administration is provided when appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As previously stated, a psychiatrist is scheduled to be on-site 16 hours per week (as of February 2011). There are also on-call psychiatric services available as needed. Med-Staff and Edgewater do not have adequate policies regarding psychotropic medication administration, and the County and its consultants have not had an opportunity to verify through an auditing review the practices in this area.
Recommendations for next 6 months:
1. Develop and implement the relevant policy and procedure. 2. Verify through an auditing review current practices in this area.
b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physician on a regular, timely basis for appropriateness or adjustment. LCJ shall ensure that changes to inmates' psychotropic medications are clinically justified and documented.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As previously stated, a psychiatrist is scheduled to be on-site 16 hours per week (as of February 2011). There are also on-call psychiatric services available as needed. Med-Staff and Edgewater do not have adequate policies regarding psychotropic medication administration.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedures, which should include a policy and procedure relevant to medication non-adherence..
c. LCJ shall ensure timely implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated with psychotropic medications are seen regularly by a physician to monitor responses and potential reactions to those medications, including movement disorders, and provide treatment where appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As previously stated, a psychiatrist is scheduled to be on-site 16 hours per week (as of February 2011). There are also on-call psychiatric services available as needed. Med-Staff and Edgewater do not have adequate policies regarding psychotropic medication administration.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement the relevant policy and procedures, which should include a policy and procedure relevant to medication non-adherence..
C. SUICIDE PREVENTION: Settlement Agreement Part III Section C.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and procedures to ensure the appropriate management of suicidal inmates, and establish a suicide prevention program in accordance with generally accepted correctional standards of care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The current suicide prevention program has been found to be inadequate and inconsistent with the standard of care. The suicide prevention policy, last revised by Edgewater Systems in June

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2010, was reviewed and found to be inadequate and not consistent with the required provisions of the Department of Justice Settlement Agreement (DOJSA). It needs to be substantially revised and incorporated into the Lake County Jail policy manual.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the above draft policy
b. The suicide prevention policy shall include, at a minimum, the following provisions:
(1) an operational description of the requirements for both pre-service and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As discussed above, the current suicide prevention program and policy is in the process of being substantially revised.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the above draft policy
c. LCJ shall ensure suicide prevention policies include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT
Past practices were that inmates identified as suicidal were placed on “full suicide precautions” and housed on the 4th floor of the LCJ. “Full suicide precautions” included observation via cameras, removal of clothing, issuance of paper gowns, lock-down status, removal of all possessions and privileges. All inmates were on this status for minimum of 72 hours.
These conditions are extremely restrictive and not conducive to individualized treatment and assessment. The revised draft policy will remove these restrictive conditions and decisions

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regarding possessions and privileges should be on a case-by-case basis by mental health staff. On-site review of the 4th floor found numerous problems. Inmates were on suicide precautions without being properly observed by correctional staff, the observation sheets on cell doors were not accurate, officers had documented checks that were not made, officers in the control booth were not consistently watching the CCTV monitors, inmates on suicide precautions had their blankets completely covering their bodies, making proper observation impossible, inmates are on suicide precautions for days and are seen infrequently by mental health staff, and progress notes in the charts do not reflect adequate documentation of a suicide risk assessment.
Beginning in March 2011, Edgewater hired seven (7) “residential technicians” (RTs) to provide primary observation of inmates on suicide prevention and/or mental health observation. When these staff are unavailable, supervision will be provided by correctional staff. Cameras will no longer be the primary means for observing, although it will be utilized as a supplemental form of supervision. These RTs have received some instruction as to their responsibilities, but have not yet been trained, and will receive a full-day of suicide prevention later this year (along with all other staff).
In addition to RTs, paper gowns have been replaced by safety smocks. The smocks will be laundered after each use with a biodegradable bag. The new policy requires that inmates on suicide precautions are required to be issued mattresses, and suicide-resistant mattresses will be ordered. Prior practices were to remove identification brackets from inmates on suicide precautions. This is contrary to the standard correctional practice and should be corrected. All inmates will be required to retain identification brackets.
Correctional staff will continue to make rounds of all 4th floor housing areas at 30-minute intervals, unless an inmate’s medical needs require more frequent observation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the draft suicide prevention policy.
d. LCJ shall ensure security staff posts in all housing units are equipped with readily available, safely secured, suicide cut-down tools.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
1) Each control booth of the Lake County Jail housing units contain a first aid kit, Ambu bag, and rescue tool (to quickly cut through fibrous material).
2) AEDs are strategically located throughout the facility. Additional AEDs have been purchased and will be located in key areas of the facility as determined by the director of nursing.
3) The director of nursing or designee will ensure that all equipment utilized in the response

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to medical emergencies (e.g., emergency response bag, code cart, oxygen tank, AED, etc.) is inspected and in proper working order on a regular basis.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to self-monitor.
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Currently, most inmates on suicide precautions are housed in either Section 4C or 4F on the 4th floor of old jail. For the most part, these cells are relatively safe, although there are safety hazards that need to be corrected. For example, the hooks on the restraint beds, clothing hooks and ceiling ventilation grates in shower area, and ceiling ventilation grates (in Section 4C) in cells (mostly in Section 4C) are conducive to tying a ligature in a hanging attempt. Because inmates on suicide precautions will be offered daily showers (pursuant to clinical judgment), these shower areas need to be suicide-resistant.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Make the appropriate retrofitting.
f. LCJ shall document inmate suicide attempts at LCJ in an inmate's correctional record in the classification system, in order to ensure that intake staff will be aware of past suicide attempts if an inmate with a history of suicide attempts is readmitted to LCJ.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Several provisions of the Settlement Agreement speak to the requirement that staff have knowledge of any prior suicide risk of inmates who are re-admitted to the Lake County Jail. Currently, such information is not collected, therefore, not available to either medical staff at inmate or classification staff.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Any inmate placed on suicide precautions should be tagged on the “reminder” screen within CorrecTek by mental health staff. This information should not be deleted

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when the inmate is removed from suicide precautions, nor when they are released from the facility. 2. Medical staff at intake should always review the Reminder screen on CorrecTek to verify whether the detainee was previously confined in the Lake County Jail and had any history of suicidal behavior during a prior confinement. 3. Regardless of the detainee’s behavior or answers given during intake screening, a referral to mental health staff should always be initiated based on documentation reflecting suicidal behavior during an inmate’s prior confinement within the LCJ. 4. Audit the above process.
2. Suicide Precautions.
a. LCJ shall ensure that suicide prevention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Currently, all inmates are placed on “full suicide precautions, stripped of all clothing and possessions, and issued a paper gown and safety blanket. They remain on this status for a minimum of 72 hours, regardless of risk level or lethality. They are required to be monitored by CCTV and 15-minute rounds by correctional staff. This is contrary to national correctional standards and the above provision, and in the process of being revised.
The revised suicide prevention policy includes descriptions of the type of behavior and/or circumstances that necessitates “close observation” and “constant observation.” The draft policy includes two levels of observation and reads as follows:
Close Observation is reserved for the inmate who is not actively suicidal, but expresses suicidal ideation and/or has a recent prior history of self-destructive behavior and would be considered a low risk for suicide. In addition, an inmate who denies suicidal ideation or does not threaten suicide, but demonstrates other concerning behavior (through actions, current circumstances, or recent history) indicating the potential for self-injury, should be placed under close observation. This inmate should be observed by staff at staggered intervals not to exceed every 10 minutes, and should be documented as it occurs.
Constant Observation is reserved for the inmate who is actively suicidal, either by threatening or engaging in self-injury and would be considered a high risk for suicide. This inmate should be observed by an assigned staff member on a continuous, uninterrupted basis. The observation should be documented at 10minute intervals.

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Cameras can be utilized as a supplement to, but never as a substitute for, these observation levels. In addition, there are inmates on “caution” status in the 4th floor cells. This status needs to be specificity identified as either a medical or mental health observation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the suicide prevention policy.
b. LCJ shall ensure that when staff initially place an inmate on Suicide Precautions, the inmate shall be searched and monitored with constant direct supervision until a Qualified Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Until such an assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Most of these requirements are currently being practiced, but the suicide prevention policy is in need of revision. Safety smocks have been purchased and are now distributed; use of paper gowns has been discarded.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the previously referenced draft suicide prevention policy.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified 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 a Qualified Mental Health Professional, except under emergency circumstances.
Overall Compliance Rating: PARTIAL COMPLIANCE
ASSESSMENT:
As previously stated, the current management of suicidal inmates within the Lake County Jail system is overly restrictive. Confining a suicidal inmate to their cell for 24 hours a day only enhances isolation and is anti-therapeutic. Under these conditions, it is also difficult, if not impossible, to accurately gauge the source of an inmate’s suicidal ideation. As such, the suicide prevention policy has been revised and contains the following:
 All decisions regarding the removal of an inmate’s clothing, bedding, possessions (books, slippers/sandals, eyeglasses, etc.) and privileges shall be commensurate with the level of

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suicide risk as determined on a case-by-case basis by mental health staff;
 If mental health staff determine that an inmate’s clothing needs to be removed for reasons of safety, the inmate shall always be issued a safety smock and safety blanket;
 All inmates on suicide precautions shall be allowed all routine privileges (e.g., family visits, telephone calls, recreation, etc.), unless the inmate has lost those privileges as a result of a disciplinary sanction; and
 All inmates on suicide precautions shall not be locked down. They should be allowed dayroom access commensurate with their security level.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the previously referenced draft suicide prevention policy.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Staff shall assess and interact with (not just observe) inmates on Suicide Precautions on a daily basis.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Currently, only two qualified mental health professionals (QMHP) are available. One is a masters-level, licensed clinician, the other, a part-time psychiatrist whose hours were recently raised to 16 hours per week. As such, there is insufficient staff available to conduct daily assessments.
Edgewater Systems (the mental health provider) has been authorized to hire 6 additional QMHPs (masters-level) who can be licensed outside the state of Indiana. In addition, 7 residential technicians have been hired and are currently working on the 4th floor. They are primarily responsible for observing inmates on suicide precautions.
Currently, there is inadequate documentation in the medical chart regarding “mental health examinations” of inmates on suicide precautions. This provision is differentiated from Provisions C.2.e, C.3.a and C.3.b which requires a suicide risk assessment. Here, only a daily mental health examination is required as a progress note. For purposes of documentation, the progress notes should be in SOAP format and provide a sufficient description of the current behavior (mental status exam) and justification for a particular level of observation. The mental health manager is responsible to ensure that all current mental health staff begin utilizing SOAP-format to writing more robust progress notes.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

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1. Approve and implement the previously referenced draft suicide prevention policy. 2. Refer to section re: mental health staffing.
e. LCJ shall ensure that inmates will only be removed from Suicide Precautions after approval by a Qualified Mental Health Professional, in consultation with a psychiatrist, after a suicide risk assessment indicates it is safe to do so. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Currently, the masters-level QMHP is discharging inmates from suicide precautions in consultation with psychiatrist. Often, the consultation is via telephone which is permissible under this provision. When on-site (Tuesday and Wednesday), the psychiatrist often assesses inmates on suicide precautions.
Currently, treatment plans and follow-up assessments (within 7 days) for inmates released from suicide precautions are inadequate. The treatment plan, which should be contained on the suicide risk assessment, is to describe signs, symptoms, and the circumstances in which the risk for suicide is likely to recur, how recurrence of suicidal thoughts can be avoided, and actions the patient or staff can take if suicidal thoughts do occur. That is not happening.
Follow-up assessments should occur on a more frequent basis. The following requirement is contained within the revised suicide prevention policy: unless an inmate’s individual circumstances directs otherwise (e.g., an inmate inappropriately placed on suicide precautions by non-mental health staff and released less than 24 hours later following an assessment), the reassessment schedule following discharge from suicide precautions is: within 24 hours, then again within 72 hours, then again within 1 week, and then periodically until release from custody.
It appears from medical chart review that both medical and mental health staff routinely wrote “per Dr. Robbins” (the psychiatrist) even in incidences when he was not consulted. There should not be any standing physician orders in managing suicidal inmates. It is not necessary (or required by the Settlement Agreement) to receive doctor’s orders to initiate a suicide precaution.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the previously referenced draft suicide prevention policy. 2. Remedy the “per Dr. Robbins” issue described above. 3. Following implementation of this policy, perform a relevant audit.
3. Suicide Risk Assessments.

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a. LCJ shall ensure that any inmate showing signs and symptoms of suicide is assessed by a Qualified Mental Health Professional using an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Until recently, the QMHPs were not utilizing a formalized suicide risk assessment when assessing potentially suicidal inmates. Whether inmates are seen within 24 hours of initiation of suicide precautions by a QMHP is still contingent upon availability of the two QMHPs.
A Suicide Risk Assessment form has been developed and began implementation during the week of April 11, 2011. The form includes a brief mental status exam, listing of chronic and acute risk factors, listing of any protective factors, level of suicide risk (e.g., low, medium, or high), and treatment plan.
The Suicide Risk Assessment will be utilized during the initial assessment of risk that justifies an inmate’s placement on suicide precautions, as well as when the QMHP determines that the inmate no longer is in need of suicide precautions.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the previously referenced draft suicide prevention policy.
b. LCJ shall ensure that the risk assessment shall include the following and findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record: (1) description of the antecedent events and precipitating factors; (2) suicidal indicators; (3) mental status examination; (4) previous psychiatric and suicide risk history; (5) level of lethality; (6) current medication and diagnosis; and (7) recommendations or treatment plan.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
As stated in Provision, C.3.b, a suicide risk assessment form has been developed and recently implemented to include a brief mental status exam, listing of chronic and acute risk factors, listing of any protective factors, level of suicide risk (e.g., low, medium, or high), and treatment plan. The form includes the seven (7) required items above. The form template is being entered into CorrecTek.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Approve and implement the previously referenced draft suicide prevention policy.
4. Suicide Prevention Training.
a. LCJ shall review and, to the extent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:
(1) the suicide prevention policy as revised consistent with this Agreement; (2) why facility environments may contribute to suicidal behavior; (3) potential predisposing factors to suicide; (4) high risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) observation techniques; (7) searches of inmates who are placed on Suicide Precautions; (8) case studies of recent suicides and serious suicide attempts; (9) mock demonstrations regarding the proper response to a suicide
attempt; and (10) the proper use of emergency equipment, including suicide cut-down
tools.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
The LCJ does not currently have a viable and on-going suicide prevention program. National correctional standards require that all correctional, medical, and mental health staff receive both pre-service and annual in-service training in suicide prevention. Although the DOJSA does not specify a required length, the decision was made that all staff receive eight (8) hours of initial suicide prevention training, followed by two (2) hours of annual training.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Implement the revised suicide prevention policy and develop the suicide prevention curriculum.
b. Within 12 months of the effective date of this Agreement, all LCJ staff members who work with inmates shall be trained on LCJ's suicide prevention program. Staff shall demonstrate competency in the verbal and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
OVERALL COMPLIANCE RATING: NON- COMPLIANCE
ASSESSMENT:

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It is projected that the LCJ suicide prevention policy will be finalized and operational by June 2011. At that time, the suicide prevention curriculum will be revised and training can then be scheduled to begin during the Summer of 2011. All staff will need to be trained prior to December 2011.
If this schedule holds, an in-service lesson plan will be developed from the original curriculum and annual in-service training can commence in the Summer of 2012.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Implement the revised suicide prevention policy and develop the suicide prevention curriculum.
D. FIRE SAFETY: Settlement Agreement Part III Section D.
1. Fire Safety.
a. LCJ shall develop and implement a comprehensive fire safety program and ensure compliance is appropriately documented. The initial fire safety plan shall be approved by the State Fire Marshal or the Crown Point Fire Chief or Inspector. The fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever is sooner.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Based upon my review of fire safety related documents, staff interviews and personal observations, I found that there is not a comprehensive fire safety program in place. There are some components of a comprehensive fire safety place, including a process for testing the fire alarm and sprinkler system, a newly developed system for testing and inspecting fire and life safety equipment, the beginnings of a credible emergency key control system, and posted fire evacuation signs throughout the facility. However, I saw no evidence to suggest that the fire safety plan has been submitted or approved by the State Fire Marshal or Crown Point Fire Chief or Inspector. During the tour I also observed in the new part of the Jail’s housing units where inmates have been setting small fires on the metal shelving to warm food. As a result of this, some inmate cells have smoke damage to the walls and ceilings. In order for this type of violation to occur, the housing units must not be properly supervised by detention staff at all times. I also noted that there is not a fire safety inspection program in place at this Jail. Finally, I observed in several areas of the Jail and particularly in the old Jail area that rain water was seeping into light fixtures, which is a dangerous situation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County Jail officials and specifically the Facility Fire Safety Officer should

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review all existing fire related policies and procedures and ensure that they contain all of the provisions of the SA. 2. The final facility fire safety plan should be submitted to the State Fire Marshal or Crown Point Fire Chief or Inspector for approval. 3. A qualified fire safety officer should develop and implement a fire safety inspection program for the jail. 4. The jail administration should take a critical view at the lack of staffing and inmate supervision within the inmate housing units and conduct a security staffing analysis.
b. LCJ shall ensure that comprehensive fire drills are conducted every three months on each shift. LCJ shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Based upon my review of documents and interviews with staff and inmates, I found that the facility has not yet developed a fire drill program for the jail. A barrier to developing such a program may very well be that there is not a full-time fire safety officer assigned who could develop and coordinate such an effort.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The part-time fire safety officer should be assigned on a full-time status as the jail fire safety officer. The jail is very large and it is unrealistic to assume that the fire safety program can be fully developed, implemented and sustained with only a part-time person.
c. LCJ shall ensure that LCJ has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
All of the housing areas and other areas of the facility were equipped with fire and smoke alarm systems. Maintenance and storage areas were equipped with fire sprinklers as well as food service areas. During the inspection, facility staff were in the process of mounting AED’s and SCBA’s in strategic areas of the jail. There were fire extinguishers available in all areas of the jail and had been recently checked and serviced. It did not appear that the Laundry, although it is located in a separate building from the Jail, was equipped with fire sprinklers. During the inspection I also observed that the Maintenance Shop was cluttered with materials, tools,

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unusable items, furniture and equipment. I also observed a flammable storage metal container located within the Maintenance Shop that did not appear to be vented to outside of the building.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. SCBA’s should be mounted in areas of the jail that are readily accessible to staff such as hallways or entrances to housing units.
2. The local Fire Inspector should be contacted by Jail staff and verify whether or not sprinklers are required in the Laundry building.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
1. I would like to see a letter from the local Fire Inspector regarding whether or not a sprinkler is required in the Laundry. During the next tour, I will be inspecting the Maintenance Shop to see if the fire load has been addressed and the status of the flammable storage metal container.
d. LCJ shall ensure that all fire and life safety equipment is properly maintained and routinely inspected.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Jail staff have been working on identifying and ensuring that all fire and life safety equipment is properly maintained and routinely inspected. A master inventory of fire and life safety equipment was in the process of being fully developed. An initial inspection was conducted of this equipment.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A routine inspection program should be implemented to ensure that all fire and life safety equipment is properly maintained and functional.
2. The fire and life safety inspection program should be under the direct supervision of the Jail fire safety officer.
3. The inspection program should be clearly detailed in fire safety policies and procedures and become part of the facility comprehensive fire safety program.
e. LCJ shall ensure that emergency keys are appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:

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Facility staff have started to work on developing a system for emergency key management. However, a master inventory of all emergency keys is not yet complete. Also, emergency keys have not yet been identified by touch. I also observed that some emergency key rings had multiple keys within the key ring. Emergency rings should contain a minimal number of keys in order to make it efficient and manageable. Jail staff have not been trained in the use of emergency keys.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Jail staff should continue to fully develop their emergency key system. When completed, the emergency key system should be described in the facility policy and procedure manual and staff should be trained on the policy and emergency key program.
2. A set of the final emergency keys should be kept in a location outside of the jail such as the dispatch center or other accessible area.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual override in the event of an emergency in which the manual override is broken), including in the event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. LCJ shall conduct regular security inspections and provide ongoing maintenance to security devices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
During the inspection jail staff were generally knowledgeable on how the manual door unlocking system operates. Some staff were more knowledgeable that others. However, I did not see a system in place for conducting and documenting random audits for testing staff proficiency on the manual door unlocking system. I did not see evidence to demonstrate that a program of security inspections is in place for these devices. It appears that maintenance staff respond to problems with security devices such as door locks, fire and smoke barrier doors, and manual unlocking devices, but there does not seem to be a system or program in place for the regular checking and maintaining of these systems.
RECOMMENDATION FOR THE NEXT 6 MONTHS:
1. A policy and procedure should be developed and implemented that incorporates the provisions of this paragraph of the SA. The policy should specifically address an audit or inspection system for the security devices as well as the preventative maintenance program for the system.

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2. LCJ officials should commence random audits for testing staff proficiency in performing manual unlocking of all doors with the use of manual override system. These audits should be documented.
3. Additional Instructions/Documents For Next Tour: I would like to see documents that demonstrate the results of the inspections/audits that were conducted for the emergency unlocking system and staff response.
g. LCJ shall implement competency-based testing for staff regarding fire and emergency procedures.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
I saw no evidence to suggest that LCJ has developed or implemented a competency-based testing for staff regarding fire and emergency procedures. The topic of developing a staff training program has been discussed but not yet implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should develop and implement a competency-based testing for jail staff regarding fire and emergency procedures. The testing protocols should be included in the Jail fire safety policy and procedure manual and become part of the overall comprehensive fire safety plan.
h. LCJ shall ensure that fire safety officers are trained in fire safety and have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During my visit the LCJ had assigned a staff member as the facility fire safety officer. However, the duties of this individual had not been clearly articulated in writing. Also, the assigned fire safety officer was only performing fire safety related duties on a part-time basis or as needed. The assigned fire safety officer appears to have an extensive background in fire safety matters to include training in emergency responses; incident management; firefighting; public works; hazardous materials; technical rescue awareness; rescue operations; CPR and 1st Aid; use of the AED; and attended fire school and fire college.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The position of fire safety officer should become a full-time position within the jail. A facility the size of LCJ requires a full-time staff member to be able to successfully develop and implement a comprehensive fire safety program. LCJ should develop

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and implement a position description that describes the duties and responsibilities of the fire safety officer. The fire safety officer’s duties and responsibilities should be included in the fire safety policies and procedures. 2. The selected fire safety officer should receive training on basic housekeeping requirements and on the NFPA 101 Manual that describes fire safety matters in a correctional environment.
E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
I did not see evidence of a written housekeeping and sanitation plan for the jail. There are some facility policies and procedures that address select topics surrounding housekeeping and sanitation, but the overall program has not yet been developed or implemented. There is not a meaningful housekeeping and sanitation inspection program in place for routine cleaning needs. I observed that staff and inmates had been working diligently to clean and sanitize the jail; however, a sustained program cannot be maintained without adequate staff oversight of the program or in the absence of written housekeeping and sanitation plans. Inmates are not being properly supervised or instructed on acceptable housekeeping duties. During the tour I observed many inmate cells that were unsanitary and neglected, cells in need of painting, cells walls with graffiti on them, smoke damaged cells, showers with mold and mildew build-up, return air vents clogged with debris and lint and food pass port flaps and doors with food build-up and food residue.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should develop and implement meaningful written housekeeping and sanitation plans for the jail. Incorporated in these plans should be an inspection program that clearly describes daily, weekly and monthly cleaning and inspection schedules. Cleaning schedules should describe specific staff and inmate duties and responsibilities for the cleaning and sanitation program.
2. The sanitation officers should provide oversight for the housekeeping and sanitation program. The overall plans can include specific policies and procedures that describe the housekeeping and sanitation program such as staff and inmate duties and responsibilities, a description of the inspection program, and material and supply allocation and control procedures.

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b. LCJ shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The LCJ’s physical plant had been neglected for several years. The current administration has made obvious strides in refurbishing the physical plant and making needed repairs to the plumbing system. Outside contractors have been hired to conduct plumbing repairs. A work order process is in place and work orders can be tracked. The LCJ still needs to develop and implement a preventative maintenance plan for responding to routine and emergency maintenance needs on an on-going basis.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to conduct needed repairs to the physical plant and plumbing system.
2. LCJ staff should develop a written preventative maintenance plan that includes, schedules for preventative maintenance inspections and repairs, staff assignments that are responsible for inspection and repairs, a description of the work order system and an inventory of regularly needed spare parts and plumbing fixtures.
3. The above requirements should be addressed in a facility policy and procedure.
c. LCJ shall ensure adequate ventilation throughout LCJ to ensure that inmates receive an adequate supply of airflow and reasonable levels of heating and cooling. LCJ shall review and assess compliance with this requirement at least twice annually.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I observed that many inmate cells had had the air vents covered with materials thus obstructing air flow. I also observed that in many of the housing unit dayroom areas the return air flow vents were saturated with lint and debris. It is difficult to be able to achieve and maintain a balanced supply of airflow under these conditions. LCJ staff reported that an outside contractor had assessed the ventilation system and all areas had been balanced. I did not review the report of that assessment, but it does not appear that the return air vents in the dayroom areas were addressed because the debris in them is substantial and longstanding.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should intensify their efforts to ensure that cell vents are not covered by inmates. This can be partly accomplished by conducting daily cell sanitation

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inspections. 2. Maintenance staff should keep records of temperature readings of the housing units
and other areas of the jail. 3. The return air vents in the housing unit dayrooms should be regularly cleaned and
made free of debris.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
During the next tour I will expect to see documents from the outside contractor on the results of their inspections and balancing records for the ventilation system. I will also be reviewing temperature logs that record maintenance staff temperature readings for the various areas of the Jail.
d. LCJ shall ensure adequate lighting in all inmate housing and work areas and cover all light switches with exposed wires.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not detect a wholesale problem with the lighting system. LCJ staff have been working diligently on making repairs to the lighting system and replacing light bulbs and fixtures. I did not detect any exposed wiring during my inspection. There were some cells and dayrooms that had lights burned out or in need of repair. I only detected one electrical outlet in a janitor’s closet in the medical area that did not have a cover. In some areas of the jail I did detect that rain water had seeped into light fixtures which is a serious life safety hazard.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the lighting and electrical system as part of their daily housekeeping inspection program and preventative maintenance program.
2. LCJ staff should make prompt repairs to the roofing to ensure that rain water does not seep down into the lighting system.
e. LCJ shall ensure adequate pest control throughout the housing units, medical units, and food storage areas.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection of inmate housing units, program areas, the food service department, the medical area and general areas of the Jail, I did not detect a problem with pest control. The LCJ reportedly has a contract with a pest control company for these services.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

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1. LCJ should continue with their pest control program.
f. LCJ shall ensure that all inmates have access to needed hygiene supplies.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not observe a problem in this area. Inmates had in their possession needed hygiene supplies. There was a significant amount of hygiene supplies in storage areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to issue inmate hygiene supplies at intake to inmates and as needed. 2. Include in the revised Inmate Handbook hygiene issue quantities and frequency of
issue.
g. LCJ shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. LCJ shall ensure that any inmate or staff utilized to clean a biohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There does not appear to be a comprehensive coherent policy and procedure that addresses this area of operation. There seems to be several policies that in part address this area. I observed during the inspection that some areas of the facility did not have spill kits available such as in the medical area and in the medical control booth. I also observed in the medical area that none of the biohazard containers had lids on them even though they contained biohazard materials. Staff reported that staff and inmates have been trained by supply companies on biohazard spills. LCJ should have their own policy, procedure and staff and inmate training program for this area of operation, including the specific areas of the jail where spill kits and biohazard supplies are kept.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should have their own policy, procedure and staff and inmate training program for this area of operation, including the specific areas of the jail where spill kits and biohazard supplies are kept.
h. LCJ shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
The facility uses universal cleaning chemicals for cleaning biohazard spills as well as a bleach solution. I did not get an opportunity to view an actual biohazard spill cleanup while on-site.
RECOMMENDATIONS FOR THE NEXT VISIT:
1. LCJ supervisory staff should ensure that staff and inmates that clean biohazard spills follow the recommended instructions of the chemicals used for the cleanup.
i. LCJ shall inspect and replace as often as needed all frayed and cracked mattresses. LCJ shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. LCJ shall ensure that mattresses are properly sanitized between uses.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not detect any frayed or cracked mattress. There were ample supplies of inmate mattresses in storage for replenishment purposes. Inmates are assigned to clean mattresses between uses. However, I noted that the mattresses are not being properly sanitized in accordance with the sanitizing chemical instructions. Inmates who clean the mattresses as well as staff description of the process are not allowing the sprayed chemical to air dry, rather they are wiping it off almost immediately upon spraying thus not allowing the chemical to take proper effect and sanitization.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Train staff and inmates that are responsible for sanitizing mattresses on the proper use of the sanitizing chemicals. Supervisory staff should inspect and review the mattresses sanitization process and ensure it is done correctly.
j. LCJ shall ensure adequate numbers of staff to perform housekeeping duties.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has two sanitation officers. These officers provide cleaning materials to inmates and to some extent they also supervise trustee workers. However, inmate workers within the housing units receive little, if any, instruction and supervision for their cleaning duties. I found sanitation in the housing units to be poor, with some exceptions. The bigger problem seems to be the general lack of supervision of inmates in the housing units. For example, I observed one floor officer trying to provide supervision to inmates in eight pods or two housing units in the new part of the jail. In the old part of the jail, I observed one officer trying to provide supervision of

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inmates in three to six living units (pods). It is unrealistic to expect that one officer can perform all the duties required of a floor officer and be able to perform them in a qualitative manner. This inadequacy is highlighted by lack of inmate supervision whereby inmates are able to draw graffiti on their cell walls without being detected or by making small fires in the metal shelving to warm food, as well as general unsanitary conditions. I also observed that officers do not normally enter the actual inmate living areas, but rather patrol the outside of the dayrooms and the catwalks. If inmates are out of their cells, the officer does not go into the actual living area. I reviewed the Estimated Functional Jail Be Capacity Report 2010 authored by RJS and noted that the correctional officer force complement was inadequate. The report reflected a shortage of approximately 68 correctional officers. I noted a similar inadequacy as I toured the housing units as described above. There are simply an inadequate number of correctional officers deployed into the housing units to properly supervise inmates and in particular, for supervising inmates that are performing housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should closely examine their correctional officer staff and move towards providing direct inmate supervision in the inmate housing units in order to better supervise inmates and the housekeeping and sanitation program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
It is expected that LCJ officials will have commenced a process for providing adequate inmate supervision in the housing units.1 It is expected that a copy of the final “comprehensive jail staffing analysis” will be made available to DOJ staff and me for review.
2. Sanitary Laundry Procedures.
a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
It appears that the laundry operation is addressed in several LCJ policies and procedures within Chapter 15 of the LCJ Policy and Procedure Manual. Policy 15-1504 appears to be the main policy governing the laundry operation. In the procedural guidelines section of this policy, it addresses “Contaminated and Infested Clothing”. This section of the policy does not address the specific procedures for handling and washing contaminated and infested clothing, instead a reference is made to “handle in accord with procedures developed”. Those procedures were not made available to me for review. However, the specific procedures for handling and washing contaminates should be addressed in the laundry policy and procedure manual. Also, the process
1 Kenneth A. Ray with Justice Services, LLC indicated by letter dated April 1, 2011 to Sheriff Bunich and the DOJ team that a “comprehensive jail staffing analysis has been authorized…” to commence in May 2011 and to be completed in July 2011.

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for the cleaning and sanitizing of the laundry carts should also be specified in the laundry policy and procedure. I toured the laundry and found it to be very effective and well equipped. The laundry is equipped with modern washers and dryers and with a new water heating system. The washers are equipped with automatic injections of detergent and sanitizing solutions. Washing and drying times are specified in the equipment and are also automated.2
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should develop a comprehensive policy and procedure that governs the total laundry operation. The policy and procedure should include the specific procedures on the washing and handling contaminated clothing and bedding. The revised laundry policy and procedure should also include the procedures for cleaning and sanitizing the laundry carts between uses.
b. LCJ shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards (e.g., at least twice per week), and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my observations, review of documents and staff and inmate interviews, I do not believe that inmates are being provided with adequate quantities of clean clothing, underclothing and bedding. For example, laundry exchange only occurs once per week instead of the required two exchanges per week. Inmates are only provided with one uniform, one sheet, one towel, one blanket, one mattress and a laundry bag. During the tour I observed inmates washing their clothing in the sinks, showers or toilets, which is highly unsanitary. Inmates also complained that their blankets are seldom washed. I was also informed by facility staff that the indigent provisions only kick in after the inmate has been at the facility for at least 30 days. This policy can also present a hygiene problem in that inmates may not have personal underwear or in the case of female inmates, bras. However, the facility does not provide any underwear to inmates regardless of whether they are indigent or not.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is my recommendation that the inmate initial issue for bedding and hygiene consist of: one mattress; two bed sheets; two towels; and one blanket. The sheets and towels should be exchanged at least once per week, unless inmates are only issued one sheet and one towel, then they should be exchanged twice per week.3 Blankets should be

2 Although not directly a provision of the SA, I observed that the laundry van does not have a Tommy or hydraulic lift to help load and unload laundry carts. Currently, a metal ramp is used for this purpose which is risky for the officer that handles these duties due to the heaviness of the laundry carts. 3 LCJ officials recommended that inmates be issued one towel and one wash cloth and washed two times per week. This would be an acceptable practice and would be consistent with accepted correctional standards.

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exchanged at least on a monthly basis and mattress should be sanitized on a regular basis and between inmate uses.
c. LCJ shall train staff and educate inmates regarding laundry sanitation policies.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
It appears that a private vendor has been providing training to laundry staff. Security staff were provided training on the provisions of the SA as it relates to laundry issues. It does not appear that a system has been developed to educate inmates regarding laundry sanitation policies. Staff reported that the Inmate Handbook could be used as one avenue for educating inmates on laundry sanitation policies.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the provisions of the SA in their basic and on-going staff training program so that security and laundry staff are fully aware as to their obligations regarding the facility sanitation policies.
2. The inmate Handbook should be revised and include the expectations of inmates regarding laundry sanitation policies.
d. LCJ shall ensure that laundry delivery procedures protect inmates from exposure to communicable diseases by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed practices that to some extent, protects inmates from exposure to communicable diseases. For example, the laundry carts are cleaned and sanitized between uses; however, staff and inmates are not following the manufactures recommended instructions for the proper use of sanitizing chemicals. As reported earlier in this report, staff and inmates are not allowing sanitizing chemicals to air dry after application. Instead, the sanitizing chemicals are being wiped off from the surfaces prematurely and not allowing them to take the proper effect. I did not detect that clean laundry was coming into contact with dirty laundry or contaminated surfaces.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should provide instructions to staff and inmates on the proper use of sanitizing chemicals.
e. LCJ shall require inmates to provide all clothing and linens for LCJ laundering and

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prohibit inmates from washing and drying laundry outside the formal procedures.
OVERALL COMPLIANCE RATING: NON- COMPLIANCE
ASSESSMENT:
I did not see a provision in the Inmate Handbook prohibiting inmates from washing and drying laundry outside the formal procedures. During the tour I observed some inmates washing undergarments, clothing and towels in the sinks, showers or toilets. This problem is complex. For example, inmates are not issued undergarments so they may only have the pair, if any, with which they came into the jail. Particularly with the female inmates, undergarments are critical to their personal hygiene and some female inmates may only have one pair of undergarments. For those inmates that do have undergarments, they are only washed once per week. Inmates that are indigent do not get underwear as part of any institutional issue. Therefore, inmates resort to washing their clothing, undergarments and towels outside the formal procedures.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should contain a provision prohibiting inmates from washing and drying laundry outside the formal procedures.
2. Inmates should also be issued sufficient quantities of clothing and towels to provide for proper hygiene and laundered as previously recommended in this report.
3. LCJ should also consider providing newly admitted indigent inmates with a reasonable number of undergarments to provide for proper hygiene.
3. Food Service.
a. LCJ shall ensure that food service at LCJ is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures, and adequate meals are provided.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
From my observations and interviews with staff and inmates, I found that adequate meals are being provided. Meals are prepared in a safe and hygienic manner. However, I did note a problem regarding food temperatures. It does not appear that food temperatures are taken of at serving times. I also observed that once food is placed in the insulated food trays and loaded onto the food carts, they are not delivered to the inmate housing units in a prompt manner, thus losing proper temperatures at serving time. Food temperature readings that I took of food that was already placed in thermo trays and on food carts awaiting to be taken to the housing units were at unacceptable food temperature ranges. For example, the hot foods ranged between 118 and 123 degrees Fahrenheit. The cold food temperature was at approximately 65 degrees Fahrenheit. The proper food temperatures for the hot food should have been approximately 135140 degrees Fahrenheit and the cold foods at approximately at 41 degrees Fahrenheit.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Supervisory staff should monitor food service operations and ensure that food service staff are obtaining and recording food temperatures during placement of food into the thermo trays and at serving times.
2. Supervisory staff should ensure that food temperatures are proper and safe for serving.
b. LCJ shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Food service staff described the food service training program verbally to me. However, it does not appear that there are training records for all food service staff. Staff training for food service staff is informal. It is difficult to determine whether or not all food service staff are being trained on the specific provisions of this paragraph of the SA in the absence of staff training records and training lesson plans and staff sign-in sheets. On a practical level, food service staff appear to be knowledgeable of food service operations. During the tour, I also observed that there is not adequate control and accountability for chemicals such as lime scale remover, detergents, pot and pan soap, bleach, degreaser and spray oven cleaner. There were also no Material Safety Data Sheets available for these chemicals. The control of caustic, toxic and hazardous materials should be part of the food service training program for food service personnel and assigned inmates.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should develop and maintain training records for food service staff and at a minimum, address the training topics required by this paragraph of the SA. All food service training provided should be well documented.
2. Food service personnel should establish policies, procedures and practices regarding the control of caustic, toxic and hazardous material used in the kitchen. Material Safety Data Sheets should be made readily available in the kitchen.
c. LCJ shall ensure that kitchen(s) are staffed with a sufficient number of appropriately supervised and trained personnel.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There are eleven food service personnel, including the food service supervisor assigned to the kitchen. The food service operation is supplemented with inmate workers. Extensive work has

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been done to repair and/or replace food service equipment. The number of food service personnel assigned to operate the kitchen appears to be adequate.4 However, there are no individual training records maintained of staff training and re-training.5
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should develop and maintain individualized training records for all food service personnel. The training records should document both on-site and off-site training and any past training that was provided to kitchen personnel on food service matters.
d. LCJ shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the tour, I found dishes and utensils, food preparation and storage areas to be clean and sanitary. However, I also noted that the food service delivery carts and food tray storage carts were not appropriately cleaned and sanitized. For example, I noted build-up of food particles on these two types of carts.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the cleaning and sanitizing of food service delivery carts and food tray storage carts be incorporated into the daily, weekly and monthly sanitation inspection program.
e. LCJ shall check and record, on a regular basis, the temperatures in the refrigerators, coolers, walk-in-refrigerators, the dishwasher water, and all other kitchen equipment with temperature monitors to ensure proper maintenance of food service equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:

4 It appears that the comprehensive jail staffing analysis that was scheduled in May 2011 will also include food service staffing. 5 Although not directly addressed in a provision of the SA, I observed in the dry storage area of the kitchen that the camera does not capture all areas, such as the desk area where an inmate worker is assigned and other areas within the dry storage. Staff reported that there could be occasions where an inmate worker is left unattended or unsupervised for a short period of time. This is an unacceptable security and safety practice.

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According to LCJ food service personnel and based on my observations during the tour, I noted that food service personnel started recording walk-in refrigerator and freezer temperatures in January of 2011. Dishwasher temperatures are taken every 2-3 days.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is my recommendation that temperatures of all refrigerators, coolers, walk-in refrigerators and the dishwasher water be checked and recorded on a daily basis. This will allow food service staff to detect a temperature problem promptly so it can be corrected.
F. QUALITY IMPROVEMENT PROGRAM: Settlement Agreement Part III Section F.
1. LCJ shall develop and implement written quality management policies and procedures to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreement, as applicable.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
LCJ currently has a QA committee but is nonfunctional. There are no existing QA policies or procedure. The current healthcare provider QA policies are nonfunctional.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Develop and implement policies and procedures relevant to quality improvement/quality management.
2. LCJ shall develop and implement policies to address and correct deficiencies that are uncovered during the course of quality management activities, including monitoring corrective actions over time to ensure sustained resolution.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
Previously used and existing policies and procedures are under review. Metrics and compliance goals have not yet been developed. Methods and process for ensuring sustained compliance need to be established and implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Review existing program documents, update, amend, etc. The QA program should be global to cover all Settlement Agreement provisions; clarify conditions and circumstances contributing to inconsistent program management.

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2. Develop relevant policies and procedures and begin implementation.
3. LCJ shall institute a Quality Improvement Committee and ensure that such committee meets on a monthly basis and that this committee includes representatives from medical, mental health, and custody staff.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
A team has been put in place and meetings are scheduled for the 2nd and 4th Thursday of each month. Until otherwise determined, the QA workgroup shall serve as the QIC. A healthcare QIC subcommittee has been established to improve process and resource efficiency. The QIC Healthcare sub-committee reports to and collaborates with the QIC.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Review existing program documents, update, amend, etc. The QA program should be global to cover all Settlement Agreement provisions; clarify conditions and circumstances contributing to inconsistent program management.
2. Develop relevant policies and procedures and begin implementation. 3. The QIC should meet twice monthly. 4. Department heads should review the QA program make committee member
appointments for their respective departments. All Settlement Agreement Compliance Inspectors should be members of the QIC.
4. Quality management programs related to medical and mental health care will utilize performance measurements to assess quality of care and timely access to care with quantitative and qualitative data analysis and trending over time and specifically shall address:
a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of
suicide attempts, monitoring of inmates on suicide observations or precautions; d. the appropriateness of physical plant facilities such as safe cells for
management of at risk inmates, and follow-up and treatment for those who may have engaged in suicidal or self-harm activities; e. the appropriateness of treatment planning and treatment interventions for inmates in the mental health program; f. discharge planning for the effective management and continuity of care for inmates leaving the system; and g. the quality of medical records and other documentation.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE

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ASSESSMENT:

Oversight and the QIC should implement this provision and review proposed metrics for core measures.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Review existing program documents, update, amend, etc. The QA program should be global to cover all Settlement Agreement provisions; clarify conditions and circumstances contributing to inconsistent program management.
2. Develop relevant policies and procedures and begin implementation.

G. PROTECTION FROM HARM: Settlement Agreement Part III Section G.

5. Use of Force by Staff.

a. LCJ shall develop and maintain comprehensive and contemporary policies and procedures surrounding the use of force and with particular emphasis regarding permissible and impermissible use of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

Prior to the tour, I was provided with a copy of LCJ’s Use of Force Policy and Procedure, contained in Chapter # 8-808. The date of the last revision for this policy and procedure is recorded as September 1, 2010. This version of the Use of Force policy and procedure is inadequate and does not address the substantive requirements of the SA. However, during the tour I was provided with a copy of an undated draft Use of Force policy and procedure by Mr. Brad Hompe, Consultant with RJS Justice Services. Overall, this version of the LCJ Use of Force Policy and Procedure is comprehensive and addresses the substantive areas of the SA. This policy contains and emphasis permissible and impermissible use of force.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The draft policy concerning the Use of Force that was provided to me by Mr.

Brad Hompe should be finalized and implemented as well as providing training to all LCJ staff on it.6

b. LCJ shall address the following impermissible uses of force in its use of force policy and in the pre-service and in-service training programs for correctional officers and supervisors:

6 Any reference I make to the Use of Force Policy and Procedure in this section of the report refers to the draft version of the policy and procedure that was provided to me by Mr. Brad Hompe (the draft use of force policy and procedure).

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(1) use of force as an initial response to verbal insults or inmate threats;
(2) use of force as a response to inmates’ failure to follow instructions where there is no immediate threat to the safety of the institution, inmates, or staff, unless LCJ has attempted a hierarchy of nonphysical alternatives that are documented;
(3) use of force as punishment or retaliation;
(4) striking, hitting, or punching a restrained inmate;
(5) use of force against an inmate after the inmate has ceased to offer resistance and is under control;
(6) use of choke holds on an inmate; and
(7) use of unnecessary or excessive force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The draft Use of Force Policy and Procedure contains the provisions of paragraph b. and subparagraphs 1-7 of the SA. The only departure I noted and discussed with Mr. Brad Hompe during the tour was concerning sub-paragraph b.4. - striking, hitting, or punching a restrained inmate; The term “unnecessarily” has been added to this sub-paragraph. The rationalization given to me by Mr. Hompe for making the recommended addition to the LCJ’s Use of Force Policy and Procedure was that there could be extreme circumstances in a use of force incident that could necessitate the need to hit, strike or punch a restrained inmate. For example, if an inmate is actively attacking a staff member or other inmate, with or without a weapon, or in instances where the officer is trying to defend himself/herself from the attack, they may need to use the necessary force to control the situation. On a practical level I agree with Mr. Hompe. However, I believe that if an officer uses impermissible force outside the bounds of the use of force policy, he or she would have to justify the reason this type of force was employed. The reviewing supervisors or investigators would have to make a determination whether it was reasonable to take into consideration the totality of the circumstances. This type of extreme example can also be addressed in the staff training program on the use of force without having to alter the language of the LCJ Use of Force Policy and Procedure.
The Use of Force pre-service and in-service training program on the draft Use of Force Policy and Procedure has not yet being developed. The first step is to finalize the use of force policy and then commence with the implementation stage, which also includes the training for correctional officers and supervisors.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

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1.

LCJ officials should sign and finalize the draft Use of Force Policy and Procedure

and incorporate it into the pre-service and in-service training program for

correctional officers and supervisors. Staff should start receiving training on the

final Use of Force Policy and Procedure.

c. LCJ shall develop and implement a policy to ensure that staff adequately and promptly report all uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

In my review of the draft Use of Force Policy and Procedure, I noted that is contains this provision of the SA. However, the draft Use of Force Policy and Procedure has not yet been implemented.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. LCJ officials sign and finalize the draft Use of Force Policy and Procedure and commence its implementation.

d. LCJ shall ensure that use of force reports will:

(1) be written in specific terms in order to capture the details of the incident;

(2) contain an accurate account of the events leading to the use of force incident;

(3) include a description of the weapon or instrument(s) of restraint, if any, and the manner in which it was used;

(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;

(5) state the nature and extent of injuries sustained both by the inmate and staff member;

(6) contain the date and time medical attention was actually provided;

(7) describe, in factual terms, the type and amount of force used and precise actions taken in a particular incident and avoid use of “boiler plate” descriptions for describing force, such as, “inmate taken to the ground with the force that was necessary;” and

(8)note whether a use of force was videotaped. If the use of force is not videotaped, the reporting correctional officer and supervisor will provide

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an explanation as to why it was not videotaped.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised draft Use of Force Policy and Procedure contains the elements of this provision of the SA including sub-paragraphs d. 1-8. However, the draft Use of Force Policy and Procedure has not been approved, signed an implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedure should be finalized, signed and implementation commenced.
2. I would also recommend that a new use of force be developed and implemented that includes all the elements of this provisions of the SA.
e. LCJ shall require prompt administrative review of use of force reports. Such reviews shall include case-by-case review of individual incidents of use of force as well as more systemic review in order to identify patterns of incidents. LCJ shall incorporate such information into quality management practices and take necessary corrective action.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The draft Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. However, the draft policy and procedure has not been implemented; therefore it cannot be evaluated in totality as of yet.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedure should be approved and signed and implemented. Security staff and supervisors should start receiving training in on the Use of Force Policy and Procedure.
2. It is also my recommendation that all use of force incidents be reviewed by the Deputy Warden of Security and the Warden.
f. LCJ shall ensure that Qualified Medical Staff request that inmates sign arelease of medical records for the limited purpose of administrative and investigative review of any incident involving an inmate injury. Qualified Medical Staff will document the request and the inmate’s response. LCJ will ensure that inmates receive adequate medical care regardless of whether they consent to release their medical records.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
This provision of the SA is addressed in the draft Use of Force Policy and Procedure. However, the consultants are still working on a coordinated effort between security and medical services to ensure it is clearly understood and that these provisions are also addressed in medical policy and procedure.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the medical policies and procedures will also include these provisions of the SA and that both security and medical staff start receiving training on them.
g. LCJ shall ensure that management review of use of force reports and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical documentation of inmate injuries as reported by Qualified Medical Staff, including documentation surrounding the initial medical encounter, an anatomical drawing that depicts the areas of sustained injury, and information regarding any further medical care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the draft Use of Force Policies and Procedures. RJS consulting staff are working with the medical staff in ensuring that the medical policies and procedures address these provisions of the SA as well.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should sign, approve and implement the draft Use of Force Policy and Procedure.
2. The medical policies and procedures should also contain the provisions of this paragraph of the SA.
h. LCJ shall establish criteria that trigger referral for use of force investigations, including but not limited to, injuries that are extensive or serious; injuries involving fractures or head trauma; injuries of a suspicious nature (including black eyes, broken teeth, injuries to the genitals, etc.); injuries that require treatment at outside hospitals; and reports of events by staff and inmates that are inconsistent.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:

The draft Use of Force Policies and Procedures contain the provisions of this paragraph of the SA.7 It appears that some staff training has already been conducted regarding this provision paragraph of the SA. However, all staff need to be trained on it as part of the pre-service and annual in-service staff training program.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The draft Use of Force Policy and Procedure should be approved, signed and implemented.

i. LCJ shall develop and implement a system to track all incidents of use of force that, at a minimum, includes the following information:

(1) a tracking number; (2) the inmate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA have been incorporated into the draft Use of Force Policy and Procedure. The draft Use of Force Policy and Procedure has not yet been approved, signed or implemented. The system to track all incidents of use of force has not been implemented.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The draft Use of Force Policy and Procedure should be approved, signed an

implemented including the use of force tracking system.

j. LCJ shall ensure that as part of a use of force incident package, security supervisors shall ensure that photographs are taken of any and all reported

7 It appears that there is a typographical error on page 11, paragraph c. of the draft policy regarding the term “suspicious”. The word “suspicious” is misspelled.

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injuries sustained by inmates and staff promptly following a use of force incident. The photographs will become evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are contained in the draft Use of Force Policy and Procedure. However, the draft Use of Force Policy and Procedure has not been approved, signed or implemented. There has been some training provided on these provisions to LCJ staff. It is too early to evaluate the provisions of this paragraph in the absence of the policy implementation and full staff training.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy should be approved, signed and implemented in order to fully evaluate compliance with the SA.
k. LCJ shall establish an “early warning system” that will document and track correctional officers who regularly employ force on inmates and any complaints related to the excessive use of force, in order to alert LCJ administration to any potential need for retraining, problematic policies, or supervision lapses. Appropriate LCJ leadership, supervisors, and investigative staff shall have access to this information and monitor the occurrences.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT: An early warning system is addressed in the draft Use of Force Policies and Procedures. However, the policy has not yet been approved, signed and implemented. It is too early to evaluate the overall requirements of these provisions of this paragraph of the SA because the overall system is not yet developed and implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedure should be approved, signed and implemented.
2. Concomitant with the implementation of the Use of Force Policy and Procedure, LCJ staff should start developing and implementing the early warning system described in the draft Use of Force Policy and Procedure.
l. LCJ shall ensure that a supervisor is present during all planned uses of force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:

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This provision is addressed in the draft Use of Force Policy and Procedure, but it is not explicit. The language in the draft Use of Force policy and Procedure suggests that a supervisor will be present during planned uses of force. The draft Use of Force Policy and Procedure has not been approved, signed or implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedure should be approved, signed and implemented. The draft policy should contain the explicit language of this provision of the SA.
m. Where there is evidence of staff misconduct related to inappropriate or unnecessary force against inmates, LCJ shall initiate appropriate personnel actions and systemic remedies, as appropriate. LCJ shall discipline appropriately any correctional officer found to have:
(1) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or other staff member for reporting the use
of excessive force; or (4) interfered or failed to cooperate with an internal investigation regarding
use of force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The draft Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. However, the draft Use of Force Policies and Procedures have not been approved, signed or implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the draft Use of Force Policy and Procedure be approved, signed and implemented so that full compliance can be evaluated with respect to discipline of staff that have used inappropriate or unnecessary force against inmates.
n. LCJ shall develop and implement accountability policies and procedures for the effective and accurate maintenance, inventory and assignment of chemical and other security equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:

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The draft Use of Force Policy and Procedures address incapacitating agents, electronic control devices and the use of the restraint chair. It appears that the procedure for the maintenance, inventory and assignment for the electronic control device is addressed in the use of policy. However, the policy does not contain those controls for restraint equipment such as handcuffs and leg irons. However, LCJ may have other policies and procedures governing all security equipment, but it should be cross-reference with the Use of Force Policy and Procedure and contain the specific provisions of this paragraph of the SA. Also, the explicit procedures for the accurate maintenance, inventory and assignment of chemical agents is not addressed in the Use of Force Policy and Procedure. There also does not appear to be inventory and maintenance logs for the security equipment.8
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedures should be approved, signed and implemented.
2. The use of force policy should also either include the provisions required by this paragraph of the SA or address them in a standalone document, but ensure they are cross-referenced.
o. Use of Force Training:
(1) LCJ shall develop an effective and comprehensive training program in the appropriate use of force.
(2) LCJ shall ensure that correctional officers receive adequate training in LCJ’s use of force policies and procedures.
(3) LCJ shall ensure that correctional officers receive adequate training in use of force and defensive tactics.
(4) LCJ shall ensure that correctional officers receive pre-service and inservice training on reporting use of force and completing use of force reports.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
The staff training provisions for the requirements of this paragraph of the SA were not available. It does not appear that the overall staff training program concerning the use of force has been developed in a comprehensive manner that would address these provisions of the SA.

8 The use of the restraint chair is also addressed in the draft Use of Force Policy and Procedure. The policy governing the use of the restraint chair should be fully developed in consultation with medical and mental healthcare staff. For example, I noted that it allows an inmate to be placed in the restrain chair initially for no longer than 12 hours, but that time can be extended. The use of the restraint chair should not be used longer than is necessary and should provide for a lesser time period if the circumstances dictate.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1.LCJ should develop a staff training program for the use of force that addresses the provisions of this paragraph of the SA.
p. LCJ shall ensure that inmates may report allegations of the use of excessive force orally to any LCJ staff member, who shall reduce such reports to writing.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The draft Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. However, the draft Use of Force Policies and Procedures have not been approved, signed or implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policies and Procedures should be approved, signed and implemented.
q. LCJ shall ensure that Qualified Medical Staff question, outside the hearing of other inmates or correctional officers if appropriate, each inmate who reports for medical care with an injury, regarding the cause of the injury. If, in the course of the inmate’s medical encounter, a health care provider suspects staffon-inmate abuse, that health care provider shall immediately:
(1) take all appropriate steps to preserve evidence of the injury (e.g., photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator; (3) adequately document the matter in the inmate’s medical record; and
(4) complete an incident report.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the draft Use of Force Policy and Procedure. However, the draft Use of Force Policy and Procedures has not been approved, signed or implemented.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:

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1. The draft Use of Force Policies and Procedures should be approved, signed and implemented.
2. These provisions should also be addressed in the medical policies and procedures.
r. LCJ shall develop, assign, and train a team of specialized use of force investigators that will be charged with conducting investigations of use of force incidents. These use of force investigators shall receive at the outset of their assignment, specialized training in investigating use of force incidents and allegations.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the draft Use of Force Policies and Procedures. However, the draft Use of Force Policies and Procedures have not been approved, signed or implemented. A use of force investigative team has not developed, assigned or trained as required by these provisions of this paragraph of the SA.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policy and Procedures should be approved, signed and implemented.
2. It is further recommended that LCJ officials develop, assign, and train a team of specialized use of force investigators as required by these provisions of this paragraph of the SA.
s. LCJ shall ensure that incident reports, use of force reports and inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, that it is referred for investigation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The draft Use of Force Policies and Procedures address the provisions of this paragraph of the SA. However, the draft use of Force Policies and Procedures have not been approved, signed or implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The draft Use of Force Policies and Procedures should be approved, signed and implemented.

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SECOND COMPLIANCE REPORT LAKE COUNTY JAIL SEPTEMBER, 2011
A. MEDICAL CARE: Settlement Agreement Section III Part A.
1. LCJ shall provide adequate services to address the serious medical and mental health needs of all inmates.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
The Sheriff of Lake County has initiated his plan to establish a compliant medical program. This effort has moved this compliance rating higher. In order to put his plan in place, staffing and physical plant items need to be funded by the County Council.
A Medical Director, Dr. Farley, has been hired. In the table of organization, Dr. Farley reports to Warden Kumorek. Dr. Farley works 30 hours a week as Medical Director. Some of his hours are currently occupied with treatment of psychiatric patients because the system does not have a psychiatrist hired yet. T his has impaired Dr. Farley’s ability to work on the medical program. Valerie Kalamaras, who is a Nurse Practitioner, is the Medical Clinical Manager. She reports to Dr. Farley. M s. Kalamaras supervises medical clinical staff and contract nursing and clerical staff. Ms. Kalamaras has previous experience at the facility. A table of organization is in effect which reflects these relationships. Staff with whom I spoke are aware of who is in charge and staff respect the leadership that the Sheriff has put into place.
Nursing and clerical staff in the medical department are contract employees from Med Staff, a local vendor. The Sheriff has presented to the County Council an option to consolidate all health services as county employees supervised by contract managers reporting directly to subordinates of the Sheriff.
The Sheriff utilizes a group of contract consultants to guide the medical program. Many contract employees work through Ken Ray. T hrough this group policy development has begun. Coordination of contract employees has improved since the last visit. T wo of the consultants, Lindsay Hayes and Dr. Shansky have correctional medical experience and have the experience to provide sufficient expertise in policy development. The written response to recommendations in our last report is significantly improved from the First Progress Report. The beginnings of a team effort are in evidence, even though tangible results are not widespread.
Some members of the County Council have suggested lowering the census of the jail as an alternative to increased funding at the jail. N evertheless, physical plant items will need to be addressed unless the census is lowered to extraordinary low levels. Just in terms of the medical program, the census would have to be in the 200-400 range to eliminate a need for additional staffing.

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RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. The Sheriff must come to agreement with the County Council on which option to take in finalizing the structure of the health care team.
2. As the Sheriff develops a leadership team, the responsibility of consultants and leadership should be clear.
3. The County Council and the Sheriff must come to agreement on funding and census.
2. LCJ shall develop and implement medical care policies, procedures, and practices to address and guide all medical care and services at LCJ, including, but not limited to the following:
(1) access to medical care; (2) continuity of medication; (3) infection control; (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; (11) comprehensive health assessments; (12) mental health; (13) women's health; (14) quality management; and (15) emergent response.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
The medical consultants have begun policy development. P olicies will follow National Commission on Correctional Health Care standards. This organization of policy development is appropriate. There are drafts for 8 sections and one section has been completed. I will provide comments on t he completed policies when they are completed. T he manual still lacks facility specific procedures. The correctional consultant, Dr. Shansky, has been engaged to assist in this process. Hopefully, procedures in the policy manual will reflect actual practices in the jail.
Because policies are not yet developed, line staff are still acting without policy. Because of improvements in leadership, it is apparent that directions to staff are improved. N evertheless, until policies and procedures are completed, potential for staff drift exists. Leadership and the consultant group should focus on key policies relevant to this agreement as they work on these policies.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Develop key policies relevant to this agreement and listed in item 2. 2. Ensure leadership involvement in policy development.

3. Intake Screening and Health Assessments.

a. LCJ shall develop and implement policies and procedures to ensure that adequate medical and mental health intake screenings and health assessments are provided to all inmates within 14 days.

b. LCJ shall ensure that, upon admission to LCJ, Qualified Medical Staff utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:

(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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any of these items shall be referred for timely medical evaluation, as appropriate.

c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 day s of his or her arrival at LCJ shall include a c omplete medical history, physical examination, mental health history, and current mental status examination. The physical examination shall be conducted by Qualified Medical Staff. 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 Medical Staff shall review prior records and update tests and examinations as needed.

d. LCJ shall ensure that Qualified Medical Staff 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.

e. LCJ shall implement a medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a t imely manner, as

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medically appropriate when medically necessary. Within 24 hours of an inmate's arrival at LCJ, or sooner if medically necessary, Qualified Medical Staff shall decide whether to continue the same or comparable medication for serious medical needs. If the inmate's reported medication is discontinued or changed, a Q ualified Medical Professional shall evaluate the inmate face-toface as soon as medically appropriate and document the reason for the change.

f. LCJ shall ensure that 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 Qualified Mental Health Professional. Staff will constantly observe such inmates until they are seen by a Qualified Mental Health Professional. Incoming inmates reporting these conditions will be housed in safe conditions unless and until a Mental Health Professional clears them for housing in a medical unit, segregation, or with the general population.

g. LCJ shall ensure that all inmates at risk for, or demonstrating signs and symptoms of drug and alcohol withdrawal are timely identified. LCJ shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.

h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.

i. LCJ shall ensure that correctional officers supervising newly arrived inmates 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 the intake health screening by Qualified Medical Staff.

OVERALL COMPLIANCE RATING: Non Compliance

ASSESSMENT:

There has been no change to the intake medical space; Emergency Medical Technicians are still performing screening examinations in a public area. The intake area lacks privacy and is inadequate for medical screening. As well, an intake policy and procedure is still not in place. The purpose of intake screening and health assessment is that individuals with medical problems are first identified and then the health needs of those so identified are addressed. The current process does not meet that standard.

EMTs perform screening. Mostly EMTs identify medications accurately. H owever, EMTs clinical evaluations are not thorough. For example, on one patient an EMT identified that the patient was on 4 different medications but documented that the patient had no medical conditions. A nother patient was listed as having no m edical problems but stated he took prednisone and warfarin. T his patient was referred to mental health but not to a medical provider. This patient did not receive a 14 day assessment until 6 weeks later; the entire time the reason for use of warfarin was unidentified. These examples demonstrate poor evaluation skills.

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Also, there is a gap between when medics screen patients and a first clinician visit. At times this is longer than a week even when medical problems are identified by EMTs. This is particularly problematic for persons with serious disease. Delay in giving care to inmates with identified medical problems was commonly seen in chart reviews. This delay in assessment for serious conditions is problematic. The corollary to this is that continuity of medication was poor. On charts reviewed, clinician evaluation of medication in conjunction with an examination was not timely.
Intake screening and the follow up clinician assessment ensuring continuity of medication should be viewed as a continuum of care and should be designed as such. The current LCJ system is fragmented and inmates with medical conditions are getting lost.

One suggestion in re-design of this process is to replace EMT screening by Registered Nurse intake screening. In this design the RN would call the physician for prescription if the inmate is on prescription medication. T hen this is followed up b y health assessments by Nurse Practitioners or physicians within a few days (1-5) for persons with identified illness. The timeliness of this assessment is determined by an acuity scale which ranks severity of illness. When this type of process is done, then only persons with identified problems need to have an assessment. Inmates who are without medical conditions, trauma, or detoxification issues need not have an assessment. This type of design reduces the total number of assessments which need to be done as those normal healthy detainees are not further evaluated. This type of design requires a nursing assessment as nurses have assessment training and skills and can reliably separate those with and without conditions needing medical attention.

This type of design can also include an intake housing unit. In such an arrangement, all inmates coming into the facility would be housed in an intake unit until their Mantoux skin test and health assessment are completed. This unit would have to be close to clinic examination rooms which include a n urse triage area. S uch an arrangement would expedite intake assessments, expedite and make easier Mantoux skin testing, and would improve medication delivery to newly incarcerated inmates.

Care for detainees with drug or alcohol withdrawal issues is still not standardized. Policy has not been developed. The organization has elected to utilize the CIWA scale for alcohol withdrawal and the COWS scale for opiate withdrawal. Since EMTs are in intake, they would not have the training to initiate use of either of these scales. In addition, both the CIWA and COWS scales require clinical judgment which should be guided by a physician protocol. T his doesn’t exist yet. T his type of scale also requires a nurse capable of assessing the patient. Currently the organization is so short staffed, and there are insufficient nursing staff to actually perform these evaluations.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Registered Nurses should perform intake screening. 2. The system should perform an acuity ranking system so that those with serious medical
problems are timely seen after intake screening. Providers should prioritize those detainees with serious medical conditions.

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3. I suggest an intake unit to more efficiently perform the Mantoux skin test and physical assessment after intake screening.
4. A standardized system of review of the intake evaluations should be put in place. 5. Privacy should be established for intake screening evaluations. 6. Standardized alcohol and opiate withdrawal procedures should be developed and
synchronized with orders in the electronic record. These procedures should be approved by the Medical Director and should be consistent with standardized treatment of withdrawal syndromes.

4. Acute care.

a. LCJ shall provide adequate and timely acute care for inmates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will include timely medical appointments and follow-up medical treatment.

OVERALL COMPLIANCE RATING: Non Compliance

ASSESSMENT:

When identified, inmates requiring acute care hospitalization are sent to local area hospitals: Patients have good access to hospitalization. Records from hospitalization are uniformly present in the medical record as scanned documents. A log of hospital visits now exists. These arrangements are adequate. Although it does not contain the diagnosis, all other elements are on the log. I was told that the Medical Director reviews all hospital cases. It would be useful if errors identified in these reviews were submitted to Quality Improvement so that root cause analysis could occur.

The problems with acute care stem from lack of management of acute problems for inmates at the jail. T his is a system problem in so far that inmates with acute conditions are not being presented to provider staff. The health service request process is so broken that patients are seldom seen in a timely manner.

As example, one inmate who came into the jail told the screening EMT that he had a swollen foot that he thought was fractured. The EMT told the inmate to place a sick call request. An inmate should not have to place a sick call request for a problem which is urgent in nature. The inmate was not seen, evaluated and x-rayed for over a w eek. Another inmate with asthma missed his post intake assessment but about 2 weeks after intake injured his hand. He was seen and given naproxen without getting an x-ray. Two days later the inmate placed an inmate card for his persistent swollen hand. He was seen two days later and an x-ray was ordered. T hree weeks later the x-ray was scheduled to be done but was cancelled because the inmate had been discharged. T his inmate with a possible fracture waited almost a month for an x-ray and was ultimately discharged before it was done. These examples demonstrate that acute care for inmates is not occurring timely or does not occur at all.

There still remain problems when patients returning from acute care hospitalization. T he unwritten procedure is that a nurse evaluates the inmate immediately upon r eturn from

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hospitalization. This appears to occur in most instances. However, it does not appear that the nurse performs vital signs, assesses why the patient was hospitalized, determines if any new medications are needed or if follow up is necessary. F or example, one patient went to the hospital with dizziness. Upon return, the hospital diagnosis was not noted and vital signs were not done. Another patient went to the hospital twice. After one hospitalization, medication was erroneously ordered for him (plavix). T he patient was hospitalized a second time for an overdose. W hile at the hospital chest pain developed and a cardiac catheterization was done which was noted as normal. When he returned to the jail, his normal cardiac catheterization was not noted. The patient remained on the unnecessary medication plavix for a couple months.
Patients with acute problems should be timely evaluated and patients returning from hospitalization should be evaluated by a nurse and their care updated with a physician. Physicians should see the patients within days of the hospitalization.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Provider time should be increased so that all patients with acute illness are evaluated timely with a thorough evaluation as needed based on their condition. Otherwise these patients should be sent to a hospital ER for evaluation.
2. All inmates returning from the hospital should be seen immediately upon return by a Registered Nurse. After the nurse assessment, consultation with a physician must occur if a change in therapy has been recommended. A physician appointment should occur at least within 72 hours of hospitalization. The physician should evaluate the status of the patient and ensure that the problem which resulted in hospitalization is stabilized.
3. The organization should track all off site hospitalization and emergency room visits to include: a. Patient name b. Housing unit c. Date of service d. Hospital patient was sent to e. Reason for transfer f. Diagnosis at the hospital g. Length of stay
5. Chronic care.
a. LCJ shall develop and implement a written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.
b. LCJ shall adopt and implement appropriate written clinical practice guidelines for chronic and communicable diseases, such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, consistent with nationally accepted guidelines.

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c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.

d. LCJ shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates' individual medical records.

e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions.

f. LCJ shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care.
OVERALL COMPLIANCE RATING: Non Compliance

ASSESSMENT:

The chronic illness policy and procedure and clinical guidelines are not yet in place. The roster of persons with chronic illness is a proxy roster of people on c ertain medications. H owever, because certain medications can be used for various diseases, this list does not give an accurate roster of patients based on t heir illness. M anagement is working with the medical record software vendor to derive such a list. In part, the inability to derive this list is related to clinicians not entering an accurate diagnosis into the record.

Based on c hart review, follow up of persons with chronic illness is haphazard. O ne patient received intake screening and gave a history of being on prednisone, warfarin (a blood thinner) and an anti-ulcer drug. He was seen about 11 days later but the reasons for being on the blood thinner and the prednisone were not determined or documented in the clinician’s note. His “14 day assessment” was done 5 weeks after incarceration. H e was documented as having had a deep vein thrombosis. Typically, persons on bl ood thinner have blood tests every month to ensure safe anticoagulation. T his inmate had life threatening episodes of excessive anticoagulation. F or the first episode, the INR was 9.9 a nd his medication was temporarily discontinued. The second episode was more complicated. He complained of not having a bowel movement for a week and was given ducolax by a nurse. S ix days later a clinician saw the patient who was assessed as markedly dehydrated and with an ulcerative dry mouth. H e was sent to the hospital where he was found dehydrated but his INR was 12, a life threatening excessive anticoagulation state. This example illustrates that persons with chronic illness, in this case being on warfarin for a clot, require routine and regular follow up with blood testing INR at specified intervals. This did not happen. The exact reason for being on prednisone was never clearly documented. Another inmate documented as having diabetes and renal failure at intake was referred to a nurse who called the doctor who ordered medication and labs. The lab tests were not done. He missed a few doses of medication and complained by writing a card. T his did not result in an evaluation. A month after incarceration, the inmate received his health assessment and gave a history of diabetes, hypothyroidism, and hypertension. This was his first visit with a provider.

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The intake screening history indicating renal failure was missed. Labs were ordered and four days later labs returned indicating renal failure. It was at this time, about 6 weeks after intake that the inmate’s renal failure was identified. Renal failure in diabetes is a serious condition that needs monitoring. The inmate was scheduled to be seen by a provider two weeks after the labs were ordered but was not seen because he was not brought by custody to the clinic. As of the day of my visit he had not been seen in follow up, about three weeks after his health assessment.
Persons with disabilities are not appropriately housed in an infirmary. The 4th floor of the jail is used to house more complicated patients including those with disabilities. As constituted, this unit is not fit to house sick people. O n the day of my visit, one of the units on t he 4th floor smelled of fresh excrement. The smell emanated from feces smeared on the floor of a cell which was unoccupied but apparently not cleaned. Most of the cells were not cleaned. Ironically, this unit was used to house patients with MRSA skin infections. This unit should be sanitized regularly. T here was no shower on t he unit that could accommodate a disabled patient. T he shower in the hall had an eight inch concrete curb which did not permit use of a wheelchair. There were no grab bars and the shower was too high to be used by a disabled patient. Wheel chair patients were housed on this unit.
There were two persons with wired jaws on this unit. Although there is a call system, the staff could not locate wire cutters in the event one of the persons with wired jaws aspirated. This is a requirement.
Patients coming onto this unit are not classified as to their acuity and there are no s tandard monitoring protocols for various patients. T here are no r equirements for physician or nurse interventions. Because there is no s tructured follow up t here is a higher probability that more complicated patients will become lost to follow up on this unit.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Policy and procedure and clinical guidelines for chronic illness management must be developed.
2. Management of chronic illness should begin in intake with identification, acuity ranking and appropriate referral to a provider.
3. The providers must use a standardized method of recording problems in the electronic record which permits maintaining a roster of persons with chronic illness.
4. Physicians must manage chronic illness by seeing patients at appropriate intervals, renewing medication, and performing thorough evaluations pertinent to the chronic disease being managed.
5. Lab and other testing (EKGs) should be performed as indicated by appropriate guidelines at indicated intervals.
6. A system of management of patients with disabilities and serious medical problems equivalent to infirmary care must be established. Such a system would include: a. Admission by a physician b. Tracking of these 4th floor patients by name and diagnosis c. Acuity ranking of patients d. Defined interval evaluations by nursing and medical staff

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e. Rules for management of types of patients f. Rules for who can be admitted to the unit g. Discharge criteria h. Discharge only by a physician i. Complete access to physicians j. Adequate nursing coverage k. Physical space that accommodates ADA type patients l. A manual of care for nurses on the unit 7. Additional physician time needs to be added in order to see the volume of patients that exist. Dr. Farley should dedicate full time to medical patients; patient backlogs can be addressed after he is established seeing only medical patients.
6. Treatment and Management of Communicable Disease.
a. LCJ shall develop and implement adequate testing, monitoring, and treatment programs for management of communicable diseases, including tuberculosis ("TB"), skin infections, and sexually transmitted infections ("STIs").
b. LCJ shall develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
c. LCJ shall continue to test all inmates for TB upon booking at LCJ and follow up on test results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LCJ shall follow current CDC guidelines for management of in mates with TB infection, including providing prophylactic medication when medically appropriate. I f directed by a ph ysician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.
d. LCJ shall ensure that any negative pressure and ventilation systems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. L CJ shall document results of such testing.
e. LCJ shall develop and implement adequate guidelines to ensure that inmates receive appropriate wound care. Such guidelines will include precautions to limit the possible spread of Methicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.

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f. LCJ shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
Mantoux skin testing appears to be done for almost all inmates coming into the jail. I verified that eight of ten patients randomly checked did have the skin test performed. However, there is no policy or procedure in place governing screening for tuberculosis. Screening requirements of the Centers for Disease Control are not clear to jail leadership and are not yet specified in policy. There is no evidence of any active surveillance for MRSA. Screening for tuberculosis could be more efficient if all incoming detainees were kept in an intake pod. Now, the medical assistant placing and reading skin tests has to track detainees all over the jail. Isolation procedures have not yet been developed.
Once policy and procedure has been developed practice can be assessed against written policy.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Develop an infection control plan that includes tuberculosis screening, MRSA management and influenza management. T his plan should also include Occupational Health and Safety required blood borne pathogen practices and isolation procedures in the event of an airborne contagious disease event.
2. Develop treatment guidelines for MRSA, tuberculosis. 3. Develop vaccination procedures for influenza. 4. Develop airborne isolation procedures consistent with Centers for Disease guidelines. 5. Assign a nurse to manage infection control issues. 6. Establish surveillance tracking of tuberculosis, skin test rates, conversion rates, employee
conversion rates, and MRSA rates, 7. Establish physician oversight over infection control issues.
7. Access to Health Care.
a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.
b. LCJ shall ensure that the medical request ("sick call") process for inmates is adequate and provides inmates with adequate access to medical care. The sick call process shall include: (1) written medical and mental health care slips available in English, Spanish, and other languages, as needed; (2) a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week;

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(3) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and
(4) opportunity for all inmates, irrespective of primary language, to access medical and mental health care.
c. LCJ shall ensure that the sick call process includes logging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation of the date and summary of each request for care, the date the inmate was seen, 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. LCJ shall document the reason for and disposition of the medical or mental health care request in the inmate's medical record.
d. LCJ shall develop and implement an effective system for screening medical requests within 24 hours of submission. LCJ shall ensure sick call requests are appropriately prioritized based upon the seriousness of the medical issue.
e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
f. LCJ shall ensure that there is an adequate number of correctional officers to escort inmates to and from medical units to ensure that inmates requiring treatment have timely access to appropriate medical care.
g. LCJ shall ensure that Qualified Medical Staff make daily rounds in the isolation areas to give inmates in isolation adequate opportunities to contact and discuss medical and mental health concerns with Qualified Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medical Staff will assess inmates for new clinical findings, such as deterioration of the inmate's condition.
h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care will be provided regardless of the inmate's ability to pay. No fee-for-service shall be required for certain conditions, including health screenings, emergency care, and/or the treatment and care of conditions affecting public health, e.g., Tuberculosis, MRSA, pregnancy, etc., particularly for indigent inmates who are not covered by a health insurance plan or policy.
OVERALL COMPLIANCE RATING: Non Compliance ASSESSMENT:
Inmates in the Lake County Jail do not have timely or adequate access to health care. None of the charts reviewed demonstrated a sick call process in which triage occurs within 24 hours and a nurse face to face assessment for symptomatic problems occurs within 72 hours.
Sick call request slips are picked up da ily. These are counted daily and the daily count is tracked. However individual slips are not tracked and there is no way to assess whether all slips are triaged daily but everyone admits that slips are not triaged or evaluated timely. W ith the

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exception of picking up and counting the number of slips daily there is no f urther progress in evaluation of health service requests.
Chart reviews still show evidence of a broken system. As an example, one inmate complained of dizziness and the nurse merely wrote that the patient was already scheduled for a week later. Symptomatic complaints should be evaluated by a nurse at least within 72 hours.
Another detainee complained of burning urination but wasn’t seen for almost a week. W hen seen a sexually transmitted disease test was done and was positive but the inmate wasn’t treated for another five days. After treatment the inmate complained of further discharge but wasn’t scheduled for almost two weeks. He had another complaint later and wasn’t seen for a month.
Much of the delay in assessing patients can be directly attributed to lack of nurse staffing. In addition, approximately 40% of scheduled patients are not brought to the clinic because there is a lack of custody staff to transport them. Even if all inmates were brought for appointments, there would not be sufficient clinical space in which to see them. This system remains broken.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Sick call policy and procedure must be developed. 2. Sufficient staff should be available to evaluate all slips. 3. Nurses should triage all slips within 24 hours. 4. Emergent issues must be addressed immediately. 5. Slips that include symptoms must include a nurse face to face evaluation in a clinical
setting. This should occur no later than 72 hours based on the clinical issue. 6. A system of tracking requests should be maintained. 7. A way to document a face to face evaluation by nursing should be established in the
medical record that associates with the medical card in question. 8. The “Inmate Medical Card” should be revised to include:
a. Mental health requests b. Dental requests c. A space to date the day the card was received by medical and the date triaged by a
nurse d. A space for a nurse to write a brief triaging note. e. Typical complaint types 9. Metrics should be instituted in the Quality Improvement program to include: a. The number of requests picked up daily b. The number of slips triaged within 24 hours c. The number of slips with symptoms that had a nurse evaluation within 72 hours. d. The number of slips referred for provider evaluation. 10. A monthly nurse quality evaluation should include supervisory review of a select number of nurse evaluations to ensure adequate quality. 11. All nurse evaluations should include vital signs. 12. Nurse protocols for evaluations should be developed. T hese must be approved by the Medical Director.

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8. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates who receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimum, discharge instructions are obtained, appropriate Qualified Medical Staff reviews the information and documentation available from the visit, this review and the outside provider's documentation are recorded in the inmate's medical record, and appropriate follow-up is provided.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
A log of off site visits is now maintained. The diagnosis should be added to the log. Returning patients who go out to a hospital or emergency room now see a nurse upon return. They may call a physician for orders. However, the nurse does not document an assessment and it is not apparent that the needs of the patient are addressed or that the patient is timely followed up by providers. F or example, one inmate returned from the hospital after having a kidney stone diagnosed. Despite having a kidney stone he was not treated with any pain medication. Another patient returned from the hospital after a cardiac procedure. It wasn’t noted that he had the procedure, he was placed on the wrong medication and not timely seen by a physician.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Upon return from the hospital or off-site consultation, all patients should go to a standard central location and be evaluated by a nurse and physician. If a physician is not present, the nurse should evaluate the patient and consult with a physician regarding any change in therapy. This discussion should be documented in the medical record.
2. The patient should be schedule for a follow up ph ysician visit to discuss and evaluate disease status.
3. For quality purposes, the log should be evaluated monthly to assess whether follow up is occurring as indicated.
9. Emergency Care. a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health needs receive timely and appropriate care, including prompt referrals and transports for outside care when medically necessary.

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b. LCJ shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
OVERALL COMPLIANCE STATUS: Partial Compliance
ASSESSMENT:
Gloves were present in only one custody station but otherwise emergency equipment was present. Medical staff all had CPR training on record. However, only 71% of custody staff had CPR training. There was no evidence of training to custody staff on serious medical or mental health conditions. There was also no evidence of blood borne pathogen training.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Medical Director should develop a training module for custody staff to include serious medical conditions and blood borne pathogen issues.
2. Officers should be trained and their training should be verified in a tracking log.
10. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical and mental health needs of inmates at LCJ.
b. LCJ shall develop and implement policies, procedures, and practices to ensure timely responses to orders for medications and laboratory tests. Such policies, procedures, and practices shall be periodically evaluated to ensure timely implementation of clinician orders.
c. LCJ shall ensure that medical and mental health records are centralized, complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out of LCJ for medical care. LCJ shall obtain records of care, reports, and diagnostic tests received during outside appointments in a t imely fashion and include such records in the inmate's medical record or document the inmate's refusal to cooperate and release medical records.
e. LCJ shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
OVERALL COMPLIANCE RATING: Partial Compliance

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ASSESSMENT:
There has been some improvement in instruction on u se of the electronic record. A major deficiency is the lack of an interface to the pharmacy. As a result the pharmacy and clinical staff have different medication profiles. This is dangerous. It results in considerable nurse work in reconciliation of medication. This takes at least two hours per nursing passing medication. In addition, manual reconciliation still does not eliminate potential medication error. A s well, penetration of the wireless network means that the electronic record inconsistently works on housing units and nurses therefore document administration of medication after it is actually administered to inmates. This is inappropriate.
The medical record does not yet have a way to document phone orders and signatures by the provider who gave the phone order. The phone order can be documented but the loop needs to be closed by provider signature.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. Interfaces with the pharmacy software should be put in place. 2. Staff dedicated to software maintenance should be hired. 3. Software training should occur when new employees start work. 4. A system of reporting and tracking software issues should be instituted to ensure that
software problems are solved. 5. A report line should be available to call in the event a software problem occurs. 6. A manual back up s ystem should be in place in the event the software goes down.
Instructions in the event of software crashes should be documented in a “down time procedure”.
11. Medication Administration.
a. LCJ shall ensure that inmates receive necessary medications in a timely manner.
b. LCJ shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. LCJ shall provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
c. LCJ shall ensure that medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. LCJ shall ensure that medication administration is performed by Qualified Nursing Staff who shall administer prescription medications on a directlyobserved basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications without a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.

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e. When LCJ has advance notice of the discharge of inmates with serious medical or mental health needs, LCJ shall provide such inmates with at least a sevenday supply of appropriate prescription medication, unless a different amount is deemed medically appropriate, to serve as a br idge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. LCJ 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 LCJ. LCJ shall ensure that information about potential release or transfer of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a f ormal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications.
g. LCJ shall ensure that Qualified Medical Staff counsels all patients who refuse medication.
h. LCJ shall secure the medication room and discontinue allowing food to be stored in the medication refrigerator.
COMPLIANCE ASSESSMENT: Non Compliance
ASSESSMENT:
There is no interface with the pharmacy, so medication administration records on the electronic record do not match the medication profile of the pharmacy. This is dangerous. Nurses have to manually reconcile medication accuracy. As well nurses do not document medication as it is administered. They document administration of medication by memory as much as hours after it has been administered. This is inappropriate and likely to result in many inaccuracies. As a result of the mismatch between pharmacy records and the electronic record, nurses receive wrong medications. Because they are not receiving the right medication, they use a large box of return medication as a grab bag of medication. Nurses then pre-pour medication into envelopes prior to going out to housing units. This is not appropriate practice. Pre-pouring should not take place and medication should be documented as given when it is given.
There is still no policy and procedure governing medication administration. There is no formal Pharmacy and Therapeutic Committee. Medication renewal is performed by nurses identifying expiring medication and getting providers to re-order medication. H owever, patients are not evaluated by providers and so adequacy of therapy is not performed in the process of medication renewal.
Carts are still left in a medical administration area which is similar to a lobby. These carts should be stored in a secured area which inmates do not have access to.

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RECOMMENDATION FOR NEXT 6 MONTHS:

1. The quality committee should develop a mechanism to establish the average time from prescription to delivery of medication to the patient.
2. Policies and procedures must be developed for medication administration and storage of medication. Staff must receive regular training on these policies and procedures.
3. Medication administration must be standardized. 4. The procedure for handling refusals of medication must be standardized and developed
into policy and procedure. 5. Storage of medication carts should be in a secured area, away from civilians and inmates. 6. Medication renewal should include evaluation of the patient.

12.

Medical Facilities.

a. LCJ shall ensure that sufficient clinical space is available to provide inmates with adequate medical care services including:

(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric
and pregnant inmates).

b. LCJ shall ensure that medical areas are adequately cleaned and maintained, including installation of adequate lighting in medical exam rooms. LCJ shall ensure that hand washing stations in medical areas are fully equipped, operational and accessible.

c. LCJ shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and sharp medical tools) and hazardous waste.

d. LCJ shall provide for inmates' reasonable privacy in medical care, and maintain confidentiality of inmates' medical status, subject to legitimate security concerns and emergency situations.

OVERALL COMPLIANCE RATING: Non Compliance

ASSESSMENT:
There is no change in intake, the infirmary or the single clinic area. It is clear that the 4th floor has inadequate space for persons with disabilities. ADA facilities should be available for those who are disabled. Clinic areas in intake and on the 4th floor remain unacceptable. Reference to the first report will give details as to why the current arrangements are unacceptable.

Sick call is still occurring cell side. All clinical encounters should occur in a clinic exam room.

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RECOMMEDNATIONS FOR THE NEXT 6 MONTHS:
1. An evaluation room for medical and mental health intake evaluations must be established which permits for both security and privacy concerns.
2. Adequate clinical examination rooms need to be built for sick call request evaluations by nurses and for routine clinic examinations by providers.
3. Develop a plan for medical and mental health infirmary care housing.
13. Specialty Care.
a. LCJ shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at LCJ shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ 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 Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ shall maintain a c urrent 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, the reason for any missed or delayed appointments, and information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmates are provided adequate pre-natal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
Off site specialty appointments which do not occur are not tracked. However, staff indicate that significant numbers of off site appointments are cancelled because there are insufficient officers to transport inmates to appointments. Movement officers are not readily available so transportation is not based on need of the inmate but on the availability of an officer. This was evident in the case of a pregnant woman who was carrying a defective fetus. She failed to see an obstetrician for two months.

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Pregnancy care is still not good. Reliable obstetrical care is not available. On site management is less than adequate. There is no policy or procedure delineating care of the pregnant woman. Currently, pregnant women are placed on a special diet but there is no special housing provided. Providers do not routinely see a pregnant woman. Given that it is difficult to get appointments with the obstetrician, a pregnant woman may not see a qualified provider for weeks. When a pregnant inmate goes to the obstetrician, those records do not return to the jail so that jail staff do not know what is occurring to the inmate. Labs done at the obstetrician are not in the medical record at the facility so the providers at the facility will not know if the pregnancy is complicated or if there is something they need to be aware of. Care of pregnant women remains a liability and a patient safety issue and should be corrected.
For two consecutive monitoring visits serious problems in caring for high risk pregnant women left their fetuses exposed to potential harm by inadequate care.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Specialty appointments which are cancelled because of lack of transport officers should be tracked and reviewed by the Quality Improvement Program. The time from provider order to the appointment should be tracked and reviewed for appropriateness by the Medical Director.
2. Sufficient officer staffing should be assigned to transport patients for scheduled appointments.
3. Persons who fail to go to a scheduled appointment should be tracked and the reason for the missed appointment should be provided. This information should be provided to the Sheriff on a regular basis.
4. Pregnant females should be evaluated by an obstetrician within a week of incarceration. Prenatal lab tests can be performed routinely upon incarceration so that they will be available to the obstetrician and primary care providers at the facility.
5. Information from the obstetrician should be exchanged with the medical staff at the jail and scanned into the medical record.
6. Someone on site should be capable of performing a routine pregnancy visit for pregnant females so that care can be managed along with the obstetrician.
14. Staffing, Training and Supervision.
a. LCJ shall ensure that its health care structure is organized with clear lines of authority for its operations to ensure adequate supervision of the system's health care providers.
b. LCJ shall maintain sufficient staffing levels of Qualified Medical Staff and Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs.
c. LCJ shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious medical and mental health needs of inmates. All such staff shall receive documented orientation and inservice training on relevant topics, including identification of inmates in need of immediate or chronic care, suicide prevention, and identification and care of

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inmates with mental illness. LCJ shall ensure that all other medical and mental health staff receive adequate training to properly implement the provisions of this Agreement. d. LCJ shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision. e. LCJ shall ensure that all persons providing medical or mental health treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health staff have current, valid, and unrestricted professional licenses. f. LCJ shall ensure that correctional officers are adequately trained in identification, timely referral, and proper supervision of inmates with serious medical needs. LCJ shall ensure that correctional officers are trained to understand and identify the signs and symptoms of drug and alcohol withdrawal and to recognize and respond to other medical urgencies. g. LCJ shall ensure that correctional officers receive initial and periodic training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); recognition of signs and symptoms evidencing a response to trauma; appropriately responding to mental illness; proper supervision of inmates suffering from mental illness; and the appropriate use of force for inmates who suffer from mental illness. Such training shall be conducted by a Qualified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
There is now a Table of Organization. The Medical Director has been in place for about 6 months. Management of Med Staff has been replaced and a new Clinical Manager is in place for about a month and a half. Program leadership appears in place; they will need staff, space and equipment in order to lead the program to compliance.
Prior nurse contract numbers were not based on the functional needs of the facility. As a result, there are obvious deficiencies in nurse staffing. Current staffing is such that there are no nurses to perform health service requests; perform all assigned non-medication physician orders; perform monitoring of persons who are detoxifying from drugs or alcohol; perform infection control functions; or manage patients on t he 4th floor unit. Nurses should perform intake screening as well. Roughly, I estimate a 10-15 nurse deficit.
There is no one I have spoken with at the facility who disagrees that there is insufficient nurse staffing. If senior management constructs a staffing plan, they must ensure that functions not now being performed are included in the staff plan. I have not seen statistical data which may guide a staffing pattern but this should be done.

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Provider coverage is inadequate now largely in part because the Medical Director is providing half of his time (or more) for psychiatric coverage. A new nurse practitioner will start in October. Dental hours of 4 hours a week are grossly inadequate for a population of this size.
There is still no orientation programs except to assigned staff to various units and demonstrate to them current practice. No policy review occurs because no functional policies exist. Training is non existent including training for the electronic medical record.
Training of officers did occur in the past for certain mental health issues but I could not verify that this is occurring for medical items in the agreement. Training in accordance with terms of this agreement should be provided and the list of officers who received the training should be tracked.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A proper orientation program should be put into place for all employees. T his should include orientation to policies and procedures, security rules, and training necessary for functional competency (electronic record training, OSHA training, etc.)
2. A staffing analysis must be performed. T his should be performed after policies and procedures are complete as the procedures will determine the functional requirements (and therefore staffing levels) of the program.
3. Until a proper staffing plan is put into place immediate remediation of nursing staff should occur to correct deficiencies in health service requests, performance of nonmedication physician orders, and nursing assignments on the 4th floor.
4. Provider credentialing must be put into place. 5. Officer training must be tracked including name of officer, dates training occurred, and
type of training given.
15. Dental Care.
a. LCJ shall ensure that inmates receive adequate dental care, and follow up. Such care should be provided in a timely manner. Dental care shall not be limited to extractions.
b. LCJ shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
The dentist only comes on Fridays for about 4 hours. There was no one to interview who could inform me of dental matters.

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RECOMMENDATIONS:
1. Dental requests must be tracked in a manner similar to health service requests. 2. Patients with dental pain should not exceed a week in waiting. 3. Dental complaints with pain or infection must be evaluated by medical staff pending an
appointment with the dentist.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and related medical data, for every inmate who dies while in the custody of LCJ or under medical supervision directly from the custody of LCJ.
b. LCJ 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 LCJ personnel and shall seek to determine whether there was a pattern of symptoms that might have resulted in earlier diagnosis and intervention. Mortality and morbidity reviews shall occur within 30 days of the incident or death, and shall be revisited when the final autopsy results are available. At a minimum, the mortality and morbidity reviews shall include:
(1) critical review and analysis of the circumstances surrounding the incident;
(2) critical review of the procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental health services/reports involving the
victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures.
c. LCJ shall address any problems identified during mortality reviews through timely training, policy revision, and any other appropriate measures.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
A draft policy on Mortality Review has been written. A major problem with this policy is the implication that the Sheriff is in charge of Mortality Review; it mu st be the Medical Director. Under certain circumstances the policy permits the Mortality Review to be completed by the LCJ Legal Department. T his is unacceptable. Once the policy and procedure is completed and mortality review has begun, this section can be reviewed.

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RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. A mortality review committee should be established as part of the Quality Improvement Committee.
2. Mortality Review should be conducted by the Medical Director. In the event that there is a conflict with the Medical Director reviewing the case, an independent objective physician can perform the review.
3. Custody, mental health and medical should participate in these reviews. 4. The review should result in a document that gives recommendations for improving
aspects of care that were deficient as identified in the mortality review.
B. MENTAL HEALTH CARE: Settlement Agreement Part III Section B
1. LCJ shall provide adequate services to address the serious mental health needs of all inmates, consistent with generally accepted correctional standards of care, including sufficient staffing to meet the demands for timely access to an appropriate mental health professional, to ensure qualified mental health staff perform intake mental health screenings and evaluations, and to perform comprehensive assessments and comprehensive multidisciplinary treatment planning. See Section III. A.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
The monitoring of this provision focuses on the adequacy of the mental health staffing allocations.
As of July 31, all but one of the QMHP positions are filled (and are now county employees except for the Clinical Director) as follows:
1 – QMHP Clinical Director, Ph.D. 1 - QMHP Clinical Supervisor, LCSW 4 - QMHPs, LMHC, LCSW 1 – QMHP-C (Candidate), MSW 9 – QMHS, Crisis Stabilization/Suicide Counselors, B.S. or higher
Upon a 60-day review of the mental health needs of inmates at LCJ and staff coverage patterns, Dr. Terry Harman determined that additional 2.5 CIS positions were needed to provide immediate and direct care during high census periods. A revised Mental Health Care budget and staffing plan was prepared and has been sent to the Sheriff.
J. Farley, MD, Medical Director is currently providing medication management for this population pending recruitment of psychiatrist. The psychiatrists’ allocation, which is not adequate for the needs of the inmate population at the LCJ, will be further discussed in a later section of this report (see section B.1. e.).

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Significant LCJ correctional officer staffing allocation shortages has negatively impacted the provision of mental health services with particular reference to missed clinic appointments due to lack of COs for escorting purposes.
Recommendations for next 6 months: Obtain approval for the new mental health program model and implement this model.
Additional instructions/documents for next tour:
List of mental health staffing allocations, vacancies, and program assignments.
2. Timely and Appropriate Evaluation of Inmates.
a. LCJ shall develop and implement policies and procedures to provide adequate screening to properly identify and assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
In general, policies and procedures are either missing or outdated. M ental health policies and procedures should include the following topic areas:
1. Mission and goal 2. Administrative structure 3. Staffing (i.e., job descriptions, credentials, and privileging) 4. Reliable and valid methods for identifying inmates with severe mental illnesses (i.e.,
receiving screening, intake mental health screening, mental health evaluations) 5. Treatment programs available 6. Involuntary treatment including the use of seclusion, restraints, forced medications,
and involuntary hospitalization 7. Other medicolegal issues including informed consent and the right to refuse treatment 8. Limits of confidentiality during diagnostic and/or treatment sessions with pertinent
exceptions described 9. Mental health record requirements 10. Quality assurance and/or improvement plan 11. Training of mental health staff regarding correctional and/or security issues 12. Formal training of correctional staff regarding mental health issues 13. Research protocols
A wide range of draft policies and procedures were reviewed with administrative and consulting staff. R ecommendations were made relevant to pertinent revisions. The suicide prevention policy has been in place and implementation initiated since the last site visit.

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Recommendations for next 6 months:
Continue with development and implementation of the mental health policies and procedures as summarized above.
Recommend that “final draft” policies and procedures be sent to me for review prior to becoming approved policies and procedures.
Additional instructions/documents for next tour:
Copies of all policies and procedures finalized and/or in almost final form since the September 2011 site assessment.
b. LCJ shall ensure that the intake health screening process referred to in Section III.A.2 includes a mental health screening, which shall be incorporated into the inmate's medical records. LCJ shall ensure timely access to a Qualified Mental Health Professional when presenting symptoms of mental illness require such care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Of 21 w eekly shifts in the booking area, 12 s hifts are consistently covered by QMHS/CIS or QMHP. For the remaining 9 s hifts, the expectation was that newly admitted inmates would be screened within 24 hours. Approximately 50% of newly admitted detainees are not receiving a mental health screen within 24 hours of booking, which is obviously very concerning. It is also not very clear what percentage of inmates actually receive the mental health screening. This issue will be remedied in the near future if the shift in the mental health model is approved by the County Council.
In addition, audits by the MH Director began approximately 7/15/11. Audits revealed multiple CorrecTek (CT) issues that prevented to early recognition of inmates needing the appropriate QMHP sessions. The MH Director began the utilization of a hand written ledger of QMHP referrals that was given to Clinical Director to assign to QMHPs.
The CorrectTek issues are in the process of being fixed. Meanwhile tracking of relevant information is being done by logbooks or use of Microsoft Word.
Recommendations for next 6 months:
1. See B.1. re: recommended change in mental health program model and mental health staffing allocations.
2. Continue to work on CorrecTek refinements.

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Additional instructions/documents for next tour:
1. Provide an audit re: timeframes and completion of the intake mental health screening process.
c. LCJ shall ensure that the mental health intake screening process includes inquiry regarding:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or close
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency,
or similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
September 2011 Assessment:
The Suicide Prevention Policy implemented 7/29/11, includes the Mental Health/Suicide Risk Screening form. The revised form includes drug/alcohol withdrawal history.
The above screening instrument was implemented during the week of April 18, 2011 and later revised to include substance abuse questions during September 2011. The medical screening instrument was revised to include questions re: drug/alcohol withdrawal.
Implementation has been an issue as described in B.2.b.
Recommendations for next 6 months:
As per B.2.b.
Additional instructions/documents for next tour:
As per B.2.b.
3. Assessment and Treatment.
a. LCJ shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, or who is otherwise referred for mental health services, receives a comprehensive mental status

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evaluation in a timely manner from a Qualified Mental Health Professional (immediate for emergent issues, within 24 hours of referral for an expedited comprehensive evaluation, or 72 hours of referral for a routine comprehensive evaluation). The comprehensive mental health evaluation shall include a recorded diagnosis section, including a s tandard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If Qualified Mental Health Staff find a serious mental illness, they shall refer the inmate for appropriate treatment. LCJ shall review available information regarding any diagnosis made by the inmate's community or hospital treatment provider, and shall account for the inmate's psychiatric history as a par t of the assessment. LCJ shall adequately document the comprehensive mental status evaluation in the inmate's medical record.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
A draft policy is in place relevant to a four-page comprehensive mental health evaluation and treatment plan. The comprehensive mental health evaluation form has not been completely incorporated into CorrecTek. As a result, paper copies are being filed at the present time.
I reviewed with pertinent staff my recommendations re: significant revisions to this comprehensive mental health evaluation and treatment plan.
The mental health director has been informally auditing timeframes relevant to completion of the mental health evaluation following referrals. He reported that during the past month the required timeframes are being met once the referral has been received by the mental health services. However, it is clear that the sick call process is not working properly (refer to the report by Dr. Puisis).
Review of randomly selected medical records of mental health caseload inmates indicated that psychiatric referrals were often not being seen in a timely manner.
Recommendations for next 6 months:
1. Substantially revise the comprehensive mental health evaluation and treatment plan as discussed.
2. A formal audit should be conducted related to both the completion timeframes and quality of the assessments once the revised form has been approved and implemented.
Additional instructions/documents for next tour:
Proof of practice related to the above audit.
b. LCJ shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate

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referrals for specialty care and regularly scheduled visits with Qualified Mental Health Professionals.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Significant issues related to adequate and timely treatment for inmates with serious mental illnesses are present related to the following:
1. mental health staffing allocation and vacancy issues, 2. correctional officer allocation issues, 3. many policies and procedures were still in draft form, 4. an underdeveloped management information system (at present), 5. significant physical plant limitations, 6. lack of an active functioning QI system, 7. current mental health treatment essentially limited to medication management and limited
individual mental health counseling. Group therapy programs have not yet been initiated.
Recommendations for next 6 months:
1. As per recommendations in various sections of this report, which all impact compliance with this provision of the Settlement Agreement.
Additional instructions/documents for next tour:
As per recommendations in other pertinent sections of this report.
c. LCJ shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Since September 2011, treatment plans are being routinely developed for the following inmates:
1. Inmates placed on suicide precautions. 2. Any inmates on the fourth floor receiving mental health services. 3. All adolescent inmates in the LCJ. 4. All inmates in segregation housing units who are receiving mental health care.
The treatment plan form has not yet been included in CorrecTek.

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Recommendations for next 6 months:
1. Audit the presence of treatment plans as well as the quality of treatment plans.
Additional instructions/documents for next tour:
Provide proof of practice regarding the above recommended audits.
d. LCJ shall provide for an inmate's reasonable privacy in mental health care, and maintain confidentiality of inmates' mental health status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment:
1. Policy completed and approved per Dr. Shansky and Dr. Farley. (16.01.10 Privacy of Care).
2. Intake screenings are provided greater measure of privacy being done in the EMT room. Also, the intake renovation proposal completed for the intake health screening area is under review.
3. As of 6/22/11, QMHPs conduct 1:1 sessions in their offices with patients. However, problems persist with consistency for allowing privacy for all assessments, including suicide risk assessments. This problem centers around correctional staff availability and willingness to escort inmates to clinician offices.
4. Pursuant to the Warden’s memorandum of 8/19/11, correctional staff will be assigned to monitor the hallway outside the EMT room, where all intake screening is now required to be completed.
There continues to be inadequate space available to conduct many initial mental health screening in a private/safe manner. The current long term remedy will require funding for the proposed intake renovation proposal.
Since September 2011, the mental health clinical assessments of detainees on the 4th floor have almost always been done in a setting that provides adequate sound privacy.
Recommendations for next 6 months:
Approve a remedy for the above privacy issue.
Additional instructions/documents for next tour:
Provide a plan for implementation of the proposed remedy.

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e. LCJ shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see such inmates in a timely manner.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment:
As of February 2011, on-site psychiatric coverage had been increased to 16 hours per week. Oncall psychiatric service was also provided as needed.
Since termination of the Edgewater System contract, the LCJ has been unable to recruit a psychiatrist. LCJ continues to recruit for psychiatric services. Mark Purevich and Dr. Terry Harman contacted 30 Psychiatrists in the Lake and Porter County region. Dr. Harman compiled the list utilizing the Indiana Professional Licensing Agency’s provider list of Licensed Psychiatrists.
J. Farley, MD, Medical Director is currently providing medication management for this population pending recruitment of a psychiatrist. As of September 26, 2011, there were 195 inmates receiving psychotropic medications at the LCJ.
Marcus Wiguto, M.D. was reported to have agreed to provide 16 hours per week of psychiatric coverage, which was expected to begin during the middle of October 2011. It was unclear at present how many days per week Dr. Wiguto will be onsite at the LCJ.
Based on national guidelines for psychiatric services in jails and prisons and on my experience in such settings, it is clear that 16 hour s per week of psychiatric coverage at the LCJ will be inadequate coverage. Adequate coverage is likely to require at least 1.5 FTE psychiatrists (which could be partially filled by a psychiatric nurse practioner).
Review of randomly selected medical records of mental health caseload inmates was consistent with the above assessment based on frequent lack of documentation re: timely and/or regular appointments with Dr. Farley in the context of psychotropic medication management.
Recommendations for next 6 months:
Obtain the services of a psychiatrist as per the current psychiatrist allocation.
Obtained funding for increased psychiatrist coverage as summarized above.
Additional instructions/documents for next tour:
Provide psychiatrist staffing allocation and vacancy data.

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f. LCJ shall ensure timely and appropriate therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate space for treatment, adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
1:1 sessions with QMHPs and daily MHT rounds with patients began 6/22/11. S pace has recently been made available for group therapy purposes on the fourth floor. It was anticipated that group therapy will be started around November 2011.
4.0 FTE qualified mental health professionals and one clinical supervisor provide mental health treatment to the following inmate populations:
1. inmates on the medical/mental health housing unit on the fourth floor (generally about 30 of these inmates require mental health treatment at any given time),
2. mental health caseload for inmates in the segregation unit (generally about nine inmates), and
3. adolescent inmates (generally about nine inmates).
At the present time treatment for mental health caseload inmates on the fourth floor consists of medication management and individual counseling. Structured out of cell group therapeutic activities are currently not being offered related to physical plant limitations, which is in the process of being partially remedied. Segregation inmates generally are not receiving counseling in a setting that allows for adequate sound privacy related to both physical plant issues and correctional officer staffing allocation issues.
Treatment provided to mental health caseload inmates is often negatively impacted by the lack of adequate correctional officer allocations.
Inadequate access to inpatient psychiatric hospitalization for inmates in need of such treatment remains very problematic.
See also B.3.b.
Recommendations for next 6 months:
1. Implement group therapies as planned. 2. Negotiate better access for inpatient psychiatric care with appropriate hospital
systems. 3. As per B.3.b.

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Additional instructions/documents for next tour:
Proof of practice regarding the above
g. LCJ shall ensure mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluated by a Q ualified Mental Health Professional to determine the inmate's mental health status, which shall include an assessment of the potential effect of segregation on the inmate's mental health. During these regular evaluations, LCJ shall evaluate whether continued segregation is appropriate for that inmate, considering the assessment of the Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE September 2011 Assessment:
Qualified mental health staff (QMHS), in contrast to QMHPs, began segregation rounds in July 2011. MH staff sign in the unit log book and enter a CorrectTek (CT) segregation note for every inmate seen.
Mental health rounds are being conducted on a weekly basis in the segregation units although not by the same clinician and not always by a QMHP. A process is not yet in place relevant to the mental health assessment of the potential effects of segregation on inmates newly admitted to the segregation unit. A process is not in place relevant to assessing whether an inmate’s disciplinary sanction might in any way be mitigated by their mental illness.
It was my understanding that mental health staff have been participating in the disciplinary hearing process as a finder of fact.
Recommendations for next 6 months:
1. Mental health rounds need to be done on a weekly basis by a QHMP. It is strongly recommended that the same QMHP be assigned this duty for at least a s ix month rotation.
2. The other provisions of this SA requirement need to be implemented (e.g., presegregation mental health screening and mental health input into the disciplinary process).
3. Mental health staff should not function as “fact finders” on di sciplinary hearing boards.

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Additional instructions/documents for next tour:
1. Proof of practice that the above has been implemented.
h. LCJ 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. Each clinician shall have ready access to a c urrent log listing any prescribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and accurate information regarding any medication changes ordered in at least the past year.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
There continues to be significant management information system (MIS) issues relevant to tracking the mental health caseload at LCJ, which makes it difficult to ensure that such inmates are seen in a timely manner. Staff indicated that data relevant to the mental health caseload is provided by a special needs report that is generated through CorrecTek.
Recommendations for next 6 months:
Continue to work to find solutions to making the MIS more functional and less cumbersome to use.
Additional instructions/documents for next tour:
Proof of practice re: the above.
i. LCJ shall ensure that a Qualified Mental Health Professional conducts an in-person evaluation of an inmate prior to a medically-ordered seclusion or restraint, or as soon thereafter as possible. Patients placed in medically-ordered seclusion or restraints shall be evaluated on an on-going basis for physical and mental deterioration. Seclusion or restraint orders should include sufficient criteria for release.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE

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September 2011 Assessment:
Policies re: seclusion and restraint were in the early draft form. Fortunately, no one has been restrained for clinical reasons since the last site assessment.
Recommendations for next 6 months:
Develop and implement a policy and procedure regarding the use of restraints/seclusion for mental health purposes.
Additional instructions/documents for next tour:
Following implementation of the above policy, audit the process.
j. LCJ shall ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among inmates. Crisis services shall not be limited to administrative segregation or observation status. Inmates shall have access to appropriate licensed in-patient psychiatric care, when clinically appropriate.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment: Policies and procedures regarding psychiatric emergencies need to be developed with particular reference to use of psychotropic medications on an involuntary basis, crisis team treatment and access to inpatient psychiatric hospitalization.
Contracts with Methodist Hospital North Lake in Gary, Indiana and Regional Mental Health Center in Merrillville, Indiana for psychiatric hospital beds have been finalized. H owever, inmates with pending charges cannot be transferred to either the Methodist Hospital North Lake or the Regional Mental Health Center. S ignificant difficulties in obtaining court orders for inmates to be transferred to the state hospital in Logansport, Indiana continue to be present. It was reported that only three inmates had been transported to the state hospital in Logansport, Indiana since the last site assessment.
During this site visit there were four inmates briefly interviewed, who had been identified by staff as requiring inpatient psychiatric hospitalization, and were clearly in need of such treatment.
I recommended to administrative staff to meet with their legal counsel and, potentially, the Chief Judge of the Lake County court system to further discuss remedies to this significant problem.

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Recommendations for next 6 months:
1. Develop and implement a relevant policy and procedure regarding crisis services. 2. Remedy the lack of access to an inpatient psychiatric hospitalization for clinical
purposes.
Additional instructions/documents for next tour:
Provide a s ummary regarding efforts to remedy the lack of access to an inpatient psychiatric hospitalization for clinical purposes.
4. Psychotherapeutic Medication Administration
a. LCJ shall ensure that psychotherapeutic medication administration is provided when appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Policies and procedures relevant to this issue need to be developed.
Staffing allocations for psychiatrists’ time are not adequate as previously discussed.
Psychotropic medications are currently being managed by the CMO of the LCJ. Related to inadequate psychiatric coverage, significant medication continuity issues were present (e.g., delays in psychotropic medications being initiated). Documentation by the covering physician was very sparse based on a review of a sample of randomly selected medical records.
Recommendations for next 6 months:
Develop the relevant policies and procedures.
Audit issues related to medication continuity issues once the psychiatrist has been hired.
Additional instructions/documents for next tour:
Proof of practice regarding the above.
b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physician on a r egular, timely basis for appropriateness or adjustment. L CJ shall ensure that changes to inmates' psychotropic medications are clinically justified and documented.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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September 2011 Assessment:
The previously recommended policies and procedures relevant to medication administration should include a policy addressing medication noncompliance, required laboratory testing and continuity of medication issues.
As referenced in other sections of this report, review of inmates’ psychotropic medications by a psychiatrist or physician on a regular, timely basis for appropriateness or adjustment was problematic.
A part-time psychiatrist is to be hired by 10/19/11. See B.4.a.
Recommendations for next 6 months:
Develop the above recommended policies and procedures.
Additional instructions/documents for next tour:
Proof of practice regarding the above.
c. LCJ shall ensure timely implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated with psychotropic medications are seen regularly by a ph ysician to monitor responses and potential reactions to those medications, including movement disorders, and provide treatment where appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
As previously referenced, policies and procedures need to be developed relevant to this provision of the Settlement Agreement.
J. Farley, MD, Medical Director is currently providing medication management for this population pending recruitment. See previous discussion re: psychiatrist allocation issues in 4.a. as well as 4.b.
Recommendations for next 6 months:
As above.
Additional instructions/documents for next tour:
Proof of practice regarding the above.

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C. SUICIDE PREVENTION: Settlement Agreement Part III Section C.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and procedures to ensure the appropriate management of suicidal inmates, and establish a suicide prevention program in accordance with generally accepted correctional standards of care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
The jail suicide prevention policy has been written and approved as of July 15, 2011.
I discussed with pertinent staff some suggested revisions to this policy with specific reference to close observation and the use of restraints.
Impressive progress has been made in implementing this policy and procedure but significant gaps in implementation remain as described elsewhere in this report (e.g., mental health screening provisions, lack of daily QMHP progress notes, access to treatment, etc.).
Recommendations for next 6 months:
Incorporate the suggested revisions to the policy. Implement recommendations relevant to suicide prevention as summarized in other sections of this report.
Additional instructions/documents for next tour:
Proof of practice re: the above.
Proof of practice via audits relevant to implementation of this policy.
b. The suicide prevention policy shall include, at a minimum, the following provisions:
(1) an operational description of the requirements for both pre-service and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
OVERALL COMPLIANCE RATING: SUBSTANIAL COMPLIANCE

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September 2011 Assessment:
The suicide prevention policy includes all of the above provisions.
Additional instructions/documents for next tour:
Provide proof of practice via audits relevant to implementation of this policy.
c. LCJ shall ensure suicide prevention policies include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
September 2011 Assessment:
The suicide prevention policy contains the necessary language. Implementation will need to be audited as per C.1.a.
Recommendations for next 6 months:
See C.1.e.
Additional instructions/documents for next tour:
See C.1.e.
d. LCJ shall ensure security staff posts in all housing units are equipped with readily available, safely secured, suicide cut-down tools.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
September 2011 Assessment:
1) Each control booth of the Lake County Jail housing units contain a first aid kit, Ambu bag, and rescue tool (to quickly cut through fibrous material).
2) AEDs are strategically located throughout the facility. A dditional AEDs have been purchased and will be located in key areas of the facility as determined by the director of nursing.
3) The director of nursing or designee will ensure that all equipment utilized in the response to medical emergencies (e.g., emergency response bag, code cart, oxygen tank, AED, etc.) is inspected and in proper working order on a regular basis.

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Self-monitoring continues. Check-off sheets are developed and are required to be completed by designated staff.
Recommendations for next 6 months:
Continue to self-monitor.
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Construction work began 6/23/11 and continues with retrofitting and replacement of all 135 vent grates and other protrusions including stream cleaning and painting of each cell on the 4th floor.
Stools were present in the cells within the fourth floor that were not suicide resistant. Plans were to be developed to remedy this situation.
Recommendations for next 6 months:
Continue construction and remedy the problematic stools. Additional instructions/documents for next tour:
Remedy the above.
f. LCJ shall document inmate suicide attempts at LCJ in an inmate's correctional record in the classification system, in order to ensure that intake staff will be aware of past suicide attempts if an inmate with a history of suicide attempts is readmitted to LCJ.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
A process has been established via the suicide prevention policy and procedure that includes the following:
Whenever an inmate is discharged from suicide precautions, the designated QMHP shall enter the information into the "Past Medical History Screen" (i.e. "Suicide Precautions, Date") of the electronic medical record. T his information shall not be deleted when the inmate is removed from suicide precautions or released from the Lake County Jail.

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The EMT or other designated staff in their absence shall determine from the review of the electronic medical record (i.e., "Past Medical History Screen") whether the inmate was a medical, mental health the suicide risk during any prior confinement within the Lake County Jail. Such information shall be documented on the mental Health/Suicide Risk Intake Screening Form.
The above has not yet been implemented.
Recommendations for next 6 months:
Implement the above process.
Additional instructions/documents for next tour:
Proof of practice of the above via an audit process.
2. Suicide Precautions.
a. LCJ shall ensure that suicide prevention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE September 2011 Assessment:
Policy implemented on 7/15/11 and Warden’s memorandum of 7/29/11. The suicide prevention policy and procedure adequately addresses this element of the Settlement Agreement. The crisis stabilization technicians are performing the 10-15 minutes checks.
Recommendations for next 6 months:
Audit implementation of this policy.
Additional instructions/documents for next tour:
Provide proof of practice re: the above.
b. LCJ shall ensure that when staff initially place an inmate on Suicide Precautions, the inmate shall be searched and monitored with constant direct supervision until a Qualified Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Until such an assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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September 2011 Assessment:
Safety smocks and blankets are in use as of 6/22/11. T his portion of policy was revised previously and then implemented.
QMHPs will now be required to justify removal of clothing/issuance of smock in CT.
Recommendations for next 6 months:
Audit implementation of the above.
Additional instructions/documents for next tour:
Proof of practice re: the recommended audit.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified 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 a Qualified Mental Health Professional, except under emergency circumstances.
Overall Compliance Rating: PARTIAL COMPLIANCE September 2011 Assessment:
See C.2.b above.
Recommendations for next 6 months:
Audit the above, with particular reference to type of property restrictions imposed.
Additional instructions/documents for next tour:
Proof of practice re: this provision.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Staff shall assess and interact with (not just observe) inmates on Suicide Precautions on a daily basis.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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September 2011 Assessment:
Policy approved 7/15/11. Increased interaction utilizing MHT/CIS (QMHS) staff began 6/22/11 with daily and weekly notations in CT. QMHPs began utilizing “MH Rounds” template in CT 7/29/11. SOAP-formatted requirement issued by MH Director on 7/15/11, with expectation that new formatting will commence by 8/31/11. Auditing will then begin and be on-going.
A review of randomly selected medical records of inmates recently placed on suicide precautions indicated a lack of compliance with the requirement of daily progress notes written by a QMHP.
Recommendations for next 6 months:
Continue with relevant training/supervision.
Additional instructions/documents for next tour:
Proof of practice re: this provision of the SA.
e. LCJ shall ensure that inmates will only be removed from Suicide Precautions after approval by a Qualified Mental Health Professional, in consultation with a psychiatrist, after a suicide risk assessment indicates it is safe to do so. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment: 1. Policy implemented 7/29/11. 2. Lake County Jail will be contracting with Marcus Wigutow, MD, Board Certified Psychiatrist in October 2011 following Commissioner approval of the contract. 3. QMHPs consult with the MD and other staff and follow established guidelines before removing patient from precautions. 4. Chart audits and observation of QMHP consultations will begin once the new form is created in CT.
Recommendations for next 6 months:
Fill the psychiatrist’s vacancy.
Additional instructions/documents for next tour:
Audit compliance with this provision of the Agreement after the psychiatrist vacancy is filled.

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3. Suicide Risk Assessments.
a. LCJ shall ensure that any inmate showing signs and symptoms of suicide is assessed by a Q ualified Mental Health Professional using an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Policy implemented and the Suicide Risk Assessment form is created and placed in CT.
Recommendations for next 6 months:
Audit implementation of this provision of the Agreement.
Additional instructions/documents for next tour:
Proof of practice re: the above.
b. LCJ shall ensure that the risk assessment shall include the following and findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record: (1) description of the antecedent events and precipitating factors; (2) suicidal indicators; (3) mental status examination; (4) previous psychiatric and suicide risk history; (5) level of lethality; (6) current medication and diagnosis; and (7) recommendations or treatment plan.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
Policy implemented and the Suicide Risk Assessment form includes the required criteria as detailed above.
Issues remain re: completion of the diagnosis section of the risk management form that need to be resolved in the context of licensure requirements.
Recommendations for next 6 months:
Audit implementation of this provision of the SA.

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Additional instructions/documents for next tour:
Proof of practice re: the above.
4. Suicide Prevention Training.
a. LCJ shall review and, to the extent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:
(1) the suicide prevention policy as revised consistent with this Agreement; (2) why facility environments may contribute to suicidal behavior; (3) potential predisposing factors to suicide; (4) high risk suicide periods; (5) warning signs and symptoms of suicidal behavior; (6) observation techniques; (7) searches of inmates who are placed on Suicide Precautions; (8) case studies of recent suicides and serious suicide attempts; (9) mock demonstrations regarding the proper response to a s uicide
attempt; and (10) the proper use of emergency equipment, including suicide cut-down
tools.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
APRIL 2011 ASSESSMENT:
September 2011 Assessment:
Although the Settlement Agreement does not specify a required length, the decision was made that all staff receive eight (8) hours of initial suicide prevention training, followed by two (2) hours of annual training. The policy implemented, curriculum was developed, and trainings with Lindsay Hayes occurred from 9/12 – 13 and 9/19-20, 2011 for any staff having regular contact with LCJ inmates.
The training curriculum was reviewed, and as expected, Mr. Hayes training program was excellent.
Recommendations for next 6 months:
None
Additional instructions/documents for next tour:
None

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b. Within 12 months of the effective date of this Agreement, all LCJ staff members who work with inmates shall be trained on LCJ's suicide prevention program. Staff shall demonstrate competency in the verbal and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
September 2011 Assessment:
Policy was implemented and trainings were completed by Lindsay Hayes on 9/12 – 13 and 9/1920, 2011 for any staff having regular contact with LCJ inmates.
Over 200 ( specifically 217) employees, which represents 95% of the correctional, medical, mental health and support staffs that were eligible for training, have been trained regarding this policy during September 2011.
Recommendations for next 6 months:
Continue to monitor training needs.
Additional instructions/documents for next tour:
As above.
D. FIRE SAFETY: Settlement Agreement Part III Section D.
1. Fire Safety.
a. LCJ shall develop and implement a c omprehensive fire safety program and ensure compliance is appropriately documented. The initial fire safety plan shall be approved by the State Fire Marshal or the Crown Point Fire Chief or Inspector. T he fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever is sooner.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of fire safety related documents, staff interviews and personal observations, I found that LCJ has made progress in the development and implementation of a comprehensive fire safety program. With the assistance of Mr. Brad Hompe, a draft written comprehensive fire safety program has now been developed that includes a fire safety policy and procedure, a location guide, fire safety forms, a training schedule, a training component, a

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written test, a practical test and information regarding fire extinguisher maintenance. LCJ staff have also continued to improve their process for testing the fire alarm and sprinkler system, the inspecting of fire and life safety equipment, improvements to the emergency key control system, and the posting of fire evacuation signs throughout the facility. However, the comprehensive fire safety plan (program) still requires final approval by the Sheriff and the Jail Administrator after the internal review is completed by LCJ staff. Once the fire safety plan is approved it needs to be submitted the State Fire Marshal or Crown Point Fire Chief or Inspector for approval. During this tour and in my previous tour, I observed smoke damage to some cell walls and ceiling in the new part of the Jail. I could not determine if the damage was new or if it occurred subsequent to my previous inspection. In order for this type of violation to occur, it is clear that the housing units are not adequately supervised by detention staff as a result of staffing deficiencies.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County Jail officials and specifically the Facility Fire Safety Officer should review the draft fire safety plan and all existing fire related policies and procedures and ensure that they contain all of the provisions of the SA. The final fire safety plan should be approved by LCJ staff.
2. The final facility fire safety plan should be submitted to the State Fire Marshal or Crown Point Fire Chief or Inspector for approval.
3. The fire safety inspections process needs to be incorporated into the comprehensive fire safety plan.
4. LCJ staff should commence the process of properly staffing the jail with adequate numbers of detention staff based upon the recent staffing analysis that was conducted.
5. LCJ staff should assign the Fire Safety Officer on a full-time basis. It is unrealistic to accomplish all of the requirements of the SA in the area of fire safety and for implementing the comprehensive fire safety program with a part-time person.
b. LCJ shall ensure that comprehensive fire drills are conducted every three months on each shift. LCJ shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of documents and interviews with staff and inmates, I found that the facility has now developed a comprehensive fire drill program for the jail. A limited number of fire drills have been conducted, but LCJ staff have developed a fire drill schedule, that if fully implemented, will achieve the requirements of this provision of the SA. However, a barrier to fully implementing the comprehensive fire drill program will undoubtedly be the lack of having a full-time fire safety officer assigned with this responsibility.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The part-time fire safety officer should be assigned on a full-time status as the jail fire safety officer. The jail is very large and it is unrealistic to assume that the fire safety program can be fully implemented and sustained with only a part-time person.
c. LCJ shall ensure that LCJ has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
All of the housing areas and other areas of the facility are equipped with fire and smoke alarm systems. Maintenance and storage areas are equipped with fire sprinklers as well as food service areas. Facility staff have placed AED’s and SCBA’s in strategic areas of the jail. There were fire extinguishers available in all areas of the jail. I noted in my previous inspection that the Laundry, although it is located in a separate building from the Jail, was not equipped with fire sprinklers. I deferred judgment to the local fire authority to determine if fire sprinklers were required in the laundry. The local fire inspector determined that fire sprinklers were not required in the Laundry. During the inspection I also observed that the Maintenance Shop clutter I observed in my previous inspection has been substantially reduced; however, this area still remains a concern due to the high volume of materials, equipment and other items that are stored within. I re-inspected the flammable storage metal container located within the Maintenance Shop and it did not appear to contain gasoline or other types of fuel that require venting to outside of the building; however, if this type of flammables are to be stored in this area then the flammable storage container should ideally be placed outside of the building.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should incorporate this requirement of the SA and the process of maintaining the fire and life safety equipment into the LCJ fire safety program.
2. LCJ staff should continue to reduce the fire load in the Jail Maintenance Shop.
d. LCJ shall ensure that all fire and life safety equipment is properly maintained and routinely inspected.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The LCJ Fire Safety Officer is conducting inspections of the all fire and life safety equipment and ensuring it is properly maintained. However, the LCJ Fire Safety Officer is only assigned on a part-time basis to the fire safety program and it is uncertain if he will be able to maintain

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sustainability with this provision of the SA. Also, this component of the fire safety program needs to become part of the comprehensive fire safety program. Mr. Brad Hompe developed a draft policy and procedure that when approved by LCJ officials can be incorporated into the comprehensive fire safety program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to conduct inspections of all fire and life safety equipment and ensure it continues to be properly maintained.
2. The fire and life safety inspection program should be under the direct supervision of the Jail Fire Safety Officer.
3. The inspection program should be clearly detailed in fire safety policies and procedures and become part of the facility comprehensive fire safety program.
e. LCJ shall ensure that emergency keys are appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Facility staff have been working diligently in developing a system for emergency key management. The emergency keys have been inventoried. An emergency set of keys has been placed in the Sheriff’s Communication Center which is located outside of the Jail. Facility staff are still working on ensuring that there are ample sets of emergency keys available in the control rooms. A system of identifying emergency keys by touch has not yet been developed. During the tour, I also observed that in the Central Control Center the door cannot be closed manually due to the positioning of the emergency release component. Also, staff have not yet been trained in the use of the emergency keys.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Jail staff should continue to fully develop their emergency key system. When completed, the emergency key system should be described in the facility policy and procedure manual and staff should be trained on t he policy and emergency key program.
2. LCJ staff need to develop a system of identifying emergency keys by touch. 3. The problem identified in the Central Control Center should be promptly corrected.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual override in the event of an emergency in which the manual override is broken), including in the event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. LCJ shall conduct regular

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security inspections and provide ongoing maintenance to security devices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection, jail staff were generally knowledgeable on how the manual door unlocking system operates. Some staff were more knowledgeable that others. However, I did not see a system in place for conducting and documenting random audits for testing staff proficiency on the manual door unlocking system. I did not see evidence to demonstrate that a formal program of security inspections is in place for these devices. It appears that maintenance staff continue respond to problems with security devices such as door locks, fire and smoke barrier doors, and manual unlocking devices. LCJ staff have been checking these systems for functionality, but such checks have not yet become part of the overall fire safety program. It appears that the provisions of the SA have been addressed in the draft fire safety program and policy and procedures but have not yet been finalized, approved and implemented. Another barrier to achieving compliance with the provision of the SA is that it will be very difficult, if not impossible, for a part-time fire safety officer to oversee this program and ensure its success.
RECOMMENDATION FOR THE NEXT 6 MONTHS:
1. The draft policy and procedure that has been developed should be finalized and implemented as soon as possible as well as ensuring that it specifically addresses an audit or inspection system for the security devices as well as the preventative maintenance program for the system.
2. LCJ officials should commence random audits for testing staff proficiency in performing manual unlocking of all doors with the use of manual override system. These audits should be documented.
3. The Fire Safety Officer should be assigned on a full-time basis in order to help implement and monitor this area of the SA.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR NEXT TOUR:
I would like to see documents that demonstrate the results of the inspections/audits that were conducted for the emergency unlocking system and staff response.
g. LCJ shall implement competency-based testing for staff regarding fire and emergency procedures.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE

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ASSESSMENT:
I saw no evidence to suggest that LCJ has implemented a competency-based testing for staff regarding fire and emergency procedures. A draft policy has been developed for this area of the SA, but is not yet finalized or implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should implement a competency-based testing for jail staff regarding fire and emergency procedures. The testing protocols should be included in the Jail fire safety policy and procedure manual and become part of the overall comprehensive fire safety plan.
h. LCJ shall ensure that fire safety officers are trained in fire safety and have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has continued to assign a staff member as the facility fire safety officer. However, the duties of this individual have not been clearly articulated in writing. Also, the assigned fire safety officer is still only performing fire safety related duties on a part-time basis or as needed. The assigned fire safety officer has an extensive background in fire safety matters to include training in emergency responses; incident management; firefighting; public works; hazardous materials; technical rescue awareness; rescue operations; CPR and 1st Aid; use of the AED; and has attended fire school and fire college. Due to staff shortages, fire safety officers that will help implement the fire safety program have not yet been trained in fire safety matters or the fire safety plan.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The position of fire safety officer should become a full-time position within the jail. A facility the size of LCJ requires a full-time staff member to be able to successfully develop and implement a comprehensive fire safety program. LCJ should develop and implement a position description that describes the duties and responsibilities of the fire safety officer. T he fire safety officer’s duties and responsibilities should be included in the fire safety policies and procedures.
2. Fire safety staff or those that are assigned duties related to implementing the fire safety program need to be trained on the fire safety plan.

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E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has developed draft housekeeping and sanitation plans and inspection forms; however, there is still not a formal plan, policy and procedure in place for the routine cleaning and sanitation of the jail. Many of the jail showers are still in need of deep cleaning, but they also need to be maintained and sustained over time. Many of the facility vents are still clogged with debris and need regular cleaning. The medical area is in dire need of a daily housekeeping and sanitation program. Many of the patient cells were unsanitary and had a foul odor. Compliance staff are providing limited oversight over the sanitation process; however due to staff shortages in the housing units LCJ staff have not yet implemented an effective housekeeping and sanitation program. Overall, the facility was much cleaner during this tour than in my previous tour. I observed that staff and inmates had been working diligently to clean and sanitize the jail; however, a sustained program cannot be maintained without adequate staff oversight of the program or in the absence of having and implementing written housekeeping and sanitation plans. Inmates are still not properly supervised or instructed on acceptable housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should implement written housekeeping and sanitation plans for the jail as well as the inspection program. C leaning schedules should describe specific staff and inmate duties and responsibilities for the cleaning and sanitation program.
2. The sanitation officers should provide oversight for the housekeeping and sanitation program. The overall plans can include specific policies and procedures that describe the housekeeping and sanitation program such as staff and inmate duties and responsibilities, a description of the inspection program, and material and supply allocation and control procedures.
3. LCJ staff must ensure that the housing units are adequately supervised by detention staff and must be able to supervise inmate cleaning and sanitation processes.
b. LCJ shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The LCJ’s physical plant had been neglected for several years. The current administration continues to make strides in refurbishing the physical plant and making needed repairs to the plumbing system. A sewage grinder has been installed to better handle sewage. Numerous repairs have been made to the jail roof to prevent leaks. A work order process is in place and work orders can be tracked. The LCJ still needs to develop and implement a preventative maintenance plan for responding to routine and emergency maintenance needs on an on-going basis.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to conduct needed repairs to the physical plant and plumbing system.
2. LCJ staff should develop a written preventative maintenance plan that includes, schedules for preventative maintenance inspections and repairs, staff assignments that are responsible for inspection and repairs, a description of the work order system and an inventory of regularly needed spare parts and plumbing fixtures.
3. The above requirements should be addressed in a facility policy and procedure.
c. LCJ shall ensure adequate ventilation throughout LCJ to ensure that inmates receive an adequate supply of airflow and reasonable levels of heating and cooling. LCJ shall review and assess compliance with this requirement at least twice annually.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I observed that many inmate cells had the air vents covered with materials thus obstructing air flow. However, I did note improvement in this area from my previous inspection. I also observed that in many of the housing unit dayroom areas the return air flow vents were still saturated with lint and debris. Ensuring that cell vents are not compromised and that return air flow vents in the dayrooms are kept clean and free of debris should be part of a daily routine cleaning program. However, if detention officers are not available in the housing units to properly supervise inmates, it will be difficult, if not impossible to attain and maintain substantial compliance with the requirements of this paragraph.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should intensify their efforts to ensure that cell vents are not covered by the inmates. T his can be partly accomplished by conducting daily cell sanitation inspections. However, there must be sufficient numbers of detention officers available in the housing units in order to accomplish these tasks.

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2. Maintenance staff should continue to keep records of temperature readings of the housing units and other areas of the jail.
3. The return air vents in the housing unit dayrooms should be regularly cleaned and made free of debris.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
During the next tour I will be reviewing temperature logs that record maintenance staff temperature readings for the various areas of the Jail and will be inspecting the ventilation system.
d. LCJ shall ensure adequate lighting in all inmate housing and work areas and cover all light switches with exposed wires.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During this inspection I did not detect a wholesale problem with the lighting system. LCJ staff have continued to work diligently on making repairs to the lighting system and replacing light bulbs and fixtures. I did not detect any exposed wiring during my inspection. There were some cells and several dayrooms that had lights burned out or in need of repair. I did not detect rain water seepage into any light fixtures during this inspection.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the lighting and electrical system as part of their daily housekeeping inspection program and preventative maintenance program.
e. LCJ shall ensure adequate pest control throughout the housing units, medical units, and food storage areas.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection of inmate housing units, program areas, the food service department, the medical area and general areas of the Jail, I did not detect a problem with pest control. LCJ has pest control services that provides for regular inspections and pest control.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue with their pest control program.
f. LCJ shall ensure that all inmates have access to needed hygiene supplies.

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OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not observe a problem in this area. Inmates had in their possession needed hygiene supplies. There was a significant amount of hygiene supplies in storage areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to issue inmate hygiene supplies at intake to inmates and as needed. 2. Include in the revised Inmate Handbook hygiene issue quantities and frequency of
issue.
g. LCJ shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. LCJ shall ensure that any inmate or staff utilized to clean a bi ohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There still does not appear to be a comprehensive coherent policy and procedure that addresses this area of operation. There are several policies that in part address this area. I observed during this inspection that spill kits were available in various areas of the facility. I also observed in the medical area (exam rooms) that biohazard containers with enclosures were available. However, in the biohazard room in the medical area, there were containers with biohazard materials but they were not covered with lids.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should have their own policy, procedure and staff and inmate training program for this area of operation, including the specific areas of the jail where spill kits and biohazard supplies are kept.
h. LCJ shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE ASSESSMENT:
The facility uses universal cleaning chemicals for cleaning biohazard spills as well as a bleach solution. I did not get an opportunity to view an actual biohazard spill cleanup while on-site.

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RECOMMENDATIONS FOR THE NEXT VISIT:
1. LCJ supervisory staff should ensure that staff and inmates that clean biohazard spills follow the recommended instructions of the chemicals used for the cleanup.
i. LCJ shall inspect and replace as often as needed all frayed and cracked mattresses. LCJ shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. LCJ shall ensure that mattresses are properly sanitized between uses.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not detect any frayed or cracked mattress. There were ample supplies of inmate mattresses in storage for replenishment purposes. Inmates are assigned to clean mattresses between uses. It appears that staff and inmates are now using sanitation chemicals in accordance with the sanitizing chemical instructions. I did not observe inmates cleaning mattresses, but I did ask several inmates what the process was for cleaning and sanitizing them and their responses were proper. LCJ staff have issued written directives to the trustees and to all inmates as to the proper method of cleaning and sanitizing of mattresses.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Train staff and inmates that are responsible for sanitizing mattresses on the proper use of the sanitizing chemicals. S upervisory staff should inspect and review the mattresses sanitization process and ensure it is done correctly.
j. LCJ shall ensure adequate numbers of staff to perform housekeeping duties.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has two sanitation officers. These officers continue to provide cleaning materials to inmates and to some extent they also supervise trustee workers. However, inmate workers within the housing units continue to receive little, if any, instruction and supervision for their cleaning duties. I found sanitation in the housing units range from poor to good in some areas. The bigger problem continues to be the general lack of supervision of inmates in the housing units. For example, I observed one floor officer trying to provide supervision to inmates in eight pods or two housing units in the new part of the jail, identical to my previous finding. In the old part of the jail, I observed one officer trying to provide supervision of inmates in three to six living units (pods). It is unrealistic to expect that one officer can perform all the duties required of a floor officer and be able to perform them in a qualitative manner. This inadequacy is highlighted by lack of inmate supervision whereby inmates are able to draw graffiti on their cell walls without being detected as well as general unsanitary conditions. I also observed that officers do

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not normally enter the actual inmate living areas, but rather patrol the outside of the dayrooms and the catwalks. If inmates are out of their cells, the officer does not go into the actual living area. I reviewed the Estimated Functional Jail Be Capacity Report 2010 authored by RJS and noted that the correctional officer force complement was inadequate. The report reflected a shortage of approximately 68 correctional officers. I noted a similar inadequacy as I toured the housing units as described above. Additionally, the Sheriff’s Office presented a comprehensive Staffing Analysis that reflected a shortage of 65 detention officers in order to be able to operate the LCJ in a safe and secure manner as well as to be able to achieve substantial compliance with various provisions of the SA. There are simply an inadequate number of detention officers deployed into the housing units to properly supervise inmates and in particular, for supervising inmates that are performing housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should closely examine their correctional officer staffing levels and move towards providing direct inmate supervision in the inmate housing units in order to better supervise inmates and the housekeeping and sanitation program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
It is expected that LCJ officials will have commenced a process for providing adequate inmate supervision in the housing units.
2. Sanitary Laundry Procedures.
a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has implemented appropriate procedures for the laundry to protect inmates from risk of exposure to communicable disease. The revised policies governing this area of operation are pending review and approval. This area of operation also has staffing implications. In order for LCJ to be able to maintain the laundry operation at this level and in order to be able to implement the proposed laundry schedule, as well as to be able to adequately distribute and pickup laundry services to inmates in an orderly fashion, the laundry operation will have to expand its hours of operation as well as ensuring that there are ample numbers of detention officers in the housing units to assist in the laundry process. LCJ officials installed a hydraulic lift on the laundry transport vehicle since my last inspection which has improved officer and inmate safety in this area of operation.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should finalize their comprehensive policy and procedure that governs the total laundry operation. The policy and procedure should include the specific procedures on the washing and handling contaminated clothing and bedding. The revised laundry policy and procedure should also include the procedures for cleaning and sanitizing the laundry carts between uses.
2. LCJ should ensure that there are adequate levels of detention officers available to be able to implement the revised laundry schedule.
b. LCJ shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards (e.g., at least twice per week), and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of purchasing records and observation, LCJ officials have purchased a substantial amount of inmate clothing, bedding and towels in order to satisfy this requirement of the SA. However, due to inadequate detention officer staffing levels, LCJ officials have not distributed or issued these items to inmates in accordance with the revised inmate laundry schedule. Based upon my observations, review of documents and staff and inmate interviews, inmates are still not being provided with adequate quantities of clean clothing, underclothing and bedding. For example, laundry exchange still only occurs once per week instead of the required two exchanges per week. Inmates are only provided with one uniform, one sheet, one towel, one blanket, one mattress and a laundry bag. During this tour I observed inmates washing their clothing in the sinks, showers or toilets, which is highly unsanitary. Another problem I noted during my previous inspection and this one is that indigent provisions only kick in after the inmate has been at the facility for at least 30 days. This policy presents a hygiene problem in that inmates may not have personal underwear or in the case of female inmates, bras. However, the facility does not provide any underwear to inmates regardless of whether they are indigent or not.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is my recommendation that the inmate initial issue for bedding and hygiene consist of: one mattress; two bed sheets; two towels; and one blanket. The sheets and towels should be exchanged at least once per week, unless inmates are only issued one sheet and one towel, then they should be exchanged twice per week.1 Blankets should be exchanged at least on a monthly basis and mattresses should be sanitized on a regular basis and between inmate uses. Records of services should be maintained.
1 LCJ officials recommended that inmates be issued one towel and one wash cloth and washed two times per week. This would be an acceptable practice and would be consistent with accepted correctional standards. This recommendation was made in my previous reporting.

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2. LCJ should ensure that there are sufficient numbers of detention available in order to implement the revised laundry schedule and to distribute adequate levels of clothing and bedding items to inmates.
c. LCJ shall train staff and educate inmates regarding laundry sanitation policies.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
It appears that a private vendor has continued to provide training to laundry staff. Security staff were provided training on the provisions of the SA as it relates to laundry issues. A system has not yet been developed and implemented for educating inmates regarding laundry sanitation policies. Staff reported that the Inmate Handbook could be used as one avenue for educating inmates on laundry sanitation policies; however, formal revisions to the Inmate Handbook are pending.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the provisions of the SA in their basic and on-going staff training program so that security and laundry staff are fully aware as to their obligations regarding the facility sanitation policies.
2. The Inmate Handbook should be revised, finalized and include the expectations of inmates regarding laundry sanitation policies.
d. LCJ shall ensure that laundry delivery procedures protect inmates from exposure to communicable diseases by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed practices that protects inmates from exposure to communicable diseases. The laundry carts are cleaned and sanitized between uses. Staff and inmates are following the manufactures recommended instructions for the proper use of sanitizing chemicals. Facility staff have received training on the proper use of chemicals. Material Safety Data Sheets have been updated and are available in various areas of the jail. I did not detect that clean laundry was coming into contact with dirty laundry or contaminated surfaces. LCJ staff have provided written instructions to inmates on the proper use of sanitizing chemicals.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to provide instructions and oversight to staff and inmates on t he proper use of sanitizing chemicals and on c ross-contamination precautions.

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2. LCJ staff should continue to make available Material Safety Data Sheets in strategic areas of the jail where chemical are used and maintained.
e. LCJ shall require inmates to provide all clothing and linens for LCJ laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
OVERALL COMPLIANCE RATING: NON- COMPLIANCE
ASSESSMENT:
The Inmate Handbook has not been revised to include provisions on prohibiting inmates from washing and drying laundry outside the formal procedures. During this tour and in my previous tour, I observed some inmates washing undergarments, clothing and towels in the sinks, showers or toilets. This problem remains complex. For example, inmates are not issued undergarments so they may only have the pair, if any, with which they came into the jail. Particularly with the female inmates, undergarments are critical to their personal hygiene and some female inmates may only have one pair of undergarments. For those inmates that do have undergarments, they are only washed once per week. Inmates that are indigent do not get underwear as part of any institutional issue. Therefore, inmates resort to washing their clothing, undergarments and towels outside the formal procedures. LCJ staff have purchased additional bedding, clothing and hygiene supplies for inmates, but due to the lack of staffing, the items have not been issued
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should contain a provision prohibiting inmates from washing and drying laundry outside the formal procedures.
2. Inmates should be issued sufficient quantities of clothing and towels to provide for proper hygiene and laundered as previously recommended in this report.
3. LCJ should develop procedures for providing newly admitted indigent inmates with a reasonable number of undergarments to provide for proper hygiene.
4. LCJ officials should implement the revised laundry schedule and inmate issue provisions concomitant with an adequate facility staffing deployment plan.
3. Food Service.
a. LCJ shall ensure that food service at LCJ is operated in a s afe and hygienic manner and that foods are served and maintained at safe temperatures, and adequate meals are provided.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
From my observations and interviews with staff and inmates, I found that adequate meals continue to be provided. Meals are prepared in a safe and hygienic manner. LCJ food service staff have made improvements in the area of food temperatures. For example, temperature

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readings are taken and recorded at the time meals are placed into the serving trays. These temperatures are satisfactory. Food carts are being delivered to the housing units in a more prompt manner; however, a formal process of taking food temperatures at actual serving times has not been developed. I noted inconsistent and improper temperature readings of food at serving times. This was largely due to the lack of staff to promptly serve the meals once the food cart reaches the housing units. Some food carts remained outside the housing unit for extended periods of time awaiting the availability of a detention officer to serve the meal and thus lost considerable food temperature.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Supervisory staff should monitor food service operations and ensure that food service staff are obtaining and recording food temperatures, at least on a random basis, at actual serving times of inmate meals.
2. LCJ staff should ensure that there are sufficient numbers of detention staff available in the housing units to promptly serve the meals to inmates once they have reached the housing units.
b. LCJ shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I met with food service staff and the dietician as well as conducting an inspection of the kitchen. Many improvements have been made in this area since my last inspection. For example, training records for all food service staff have been developed. The food service training program has been formalized. Food service staff are now required to participate in the facility orientation program. Material Safety Data Sheets are available in the kitchen. Inmates are provided instructions on safe food handling procedures and proper food service preparation and appropriate sanitation practices.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to maintain their training records for food service staff and document all training provided, including food service staff orientations.
2. Food service staff should continue to ensure that Material Safety Data Sheets are readily available in the kitchen.
c. LCJ shall ensure that kitchen(s) are staffed with a sufficient number of appropriately supervised and trained personnel.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
During my previous inspection there were eleven food service personnel, including the food service supervisor assigned to the kitchen. It appears that the food service staff complement has been reduced by two workers and now there are nine food service staff positions allocated; however, two of those positions were vacant during this inspection. The food service operation continues to be supplemented with inmate workers. The number of staff assigned to the kitchen appears to be sufficient; however, the two vacant positions should be promptly filled. Food service staff training records are now in place. The camera in the dry storage area was repositioned and now provides for improved safety and security of staff and inmates.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to maintain their individualized training records for all food service personnel.
2. LCJ officials should promptly fill the two vacant food service positions.
d. LCJ shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the tour, I found dishes and utensils, food preparation and storage areas to be clean and sanitary. I also noted that the food service delivery carts and food tray storage carts were appropriately cleaned and sanitized.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the daily, weekly and monthly sanitation inspection program continues to be part of the food service system.
e. LCJ shall check and record, on a r egular basis, the temperatures in the refrigerators, coolers, walk-in-refrigerators, the dishwasher water, and all other kitchen equipment with temperature monitors to ensure proper maintenance of food service equipment.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed and implemented a system for checking and recording temperatures of the refrigerators, coolers, walk-in refrigerators and the dishwasher. LCJ staff are maintaining logs of these checks.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is my recommendation that temperatures of all refrigerators, coolers, walk-in refrigerators and the dishwasher water continue to be checked and recorded. This will allow food service staff to detect a temperature problem promptly so it can be corrected.
F. QUALITY IMPROVEMENT PROGRAM: Settlement Agreement Part III Section F.
1. LCJ shall develop and implement written quality management policies and procedures to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreement, as applicable.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE September 2011 Assessment:
Basic policies and procedures are in draft form re: a quality improvement program. Suggestions were made to relevant staff re: these policies during the site visit.
Recommendations for next 6 months:
Finalize and implement the relevant policy and procedure.
Additional instructions/documents for next tour:
Proof of practice re: the above.
2. LCJ shall develop and implement policies to address and correct deficiencies that are uncovered during the course of quality management activities, including monitoring corrective actions over time to ensure sustained resolution.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment:
F.1 policy needs to be implemented in order to implement this provision of the SA.
Recommendations for next 6 months:
See F.1.
Additional instructions/documents for next tour:
Proof of practice documents relevant to this provision of the SA.

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3. LCJ shall institute a Quality Improvement Committee and ensure that such committee meets on a monthly basis and that this committee includes representatives from medical, mental health, and custody staff.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
September 2011 Assessment:
A QI committee was recently established and has met on one occasion.
See F.1.
Recommendations for next 6 months: See F.1.
Additional instructions/documents for next tour:
See F.1.
4. Quality management programs related to medical and mental health care will utilize performance measurements to assess quality of care and timely access to care with quantitative and qualitative data analysis and trending over time and specifically shall address:
a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of
suicide attempts, monitoring of inmates on suicide observations or precautions; d. the appropriateness of physical plant facilities such as safe cells for
management of at risk inmates, and follow-up and treatment for those who may have engaged in suicidal or self-harm activities; e. the appropriateness of treatment planning and treatment interventions for inmates in the mental health program; f. discharge planning for the effective management and continuity of care for inmates leaving the system; and g. the quality of medical records and other documentation.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
September 2011 Assessment:
See F.1.
Recommendations for next 6 months:
See F.1.

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G. PROTECTION FROM HARM: Settlement Agreement Part III Section G.

5. Use of Force by Staff.

a. LCJ shall develop and maintain comprehensive and contemporary policies and procedures surrounding the use of force and with particular emphasis regarding permissible and impermissible use of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

LCJ staff, with the assistance of Brad Hompe, has developed comprehensive and contemporary policies and procedures surrounding the use of force and that emphasis permissible and impermissible use of force. The revised Use of Force policy was signed by the Sheriff on September 14, 2011.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The finalized policy concerning the Use of Force should now be implemented as

well as providing training to all LCJ staff on it.2

b. LCJ shall address the following impermissible uses of force in its use of force policy and in the pre-service and in-service training programs for correctional officers and supervisors:

(1) use of force as an initial response to verbal insults or inmate threats;

(2) use of force as a response to inmates’ failure to follow instructions where there is no immediate threat to the safety of the institution, inmates, or staff, unless LCJ has attempted a hierarchy of nonphysical alternatives that are documented;

(3) use of force as punishment or retaliation;

(4) striking, hitting, or punching a restrained inmate;

(5) use of force against an inmate after the inmate has ceased to offer resistance and is under control;

(6) use of choke holds on an inmate; and

(7) use of unnecessary or excessive force.

2 Any reference I make to the Use of Force Policy and Procedure in this section of the report refers to the final version that was signed by the Sheriff on September 14, 2011.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The final Use of Force Policy and Procedure contains the provisions of paragraph b. and subparagraphs 1-7 of the SA.

The Use of Force pre-service and in-service training program on t he Use of Force Policy and Procedure has not yet being implemented. An awareness test has been developed for the Use of Force policy. The instructor lesson plans are in the process of being developed. The trainers for the use of force training need to be identified and trained in order to help train all LCJ staff on the new Use of Force policies and procedures.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

LCJ officials need to incorporate the Use of Force policy into the pre-service and

in-service training program for correctional officers and supervisors.

2.

Staff should start receiving training on Use of Force Policy and Procedure.

c. LCJ shall develop and implement a pol icy to ensure that staff adequately and promptly report all uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policy and Procedure has been developed and it contains this provision of the SA. However, the Use of Force Policy and Procedure must now be implemented.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. LCJ officials implement the revised Use of Force Policy and Procedure.

d. LCJ shall ensure that use of force reports will:

(1) be written in specific terms in order to capture the details of the incident;

(2) contain an accurate account of the events leading to the use of force incident;

(3) include a description of the weapon or instrument(s) of restraint, if any, and the manner in which it was used;

(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;

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(5) state the nature and extent of injuries sustained both by the inmate and staff member;
(6) contain the date and time medical attention was actually provided;
(7) describe, in factual terms, the type and amount of force used and precise actions taken in a par ticular incident and avoid use of “boiler plate” descriptions for describing force, such as, “inmate taken to the ground with the force that was necessary;” and
(8) note whether a u se of force was videotaped. If the use of force is not videotaped, the reporting correctional officer and supervisor will provide an explanation as to why it was not videotaped.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the elements of this provision of the SA including sub-paragraphs d. 1 -8. T he revised Use of Force Policy and Procedure has been approved and signed and must now be implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should be implemented. 2. I would also recommend that a new use of force report form be developed and
implemented that includes all the elements of this provisions of the SA.
e. LCJ shall require prompt administrative review of use of force reports. S uch reviews shall include case-by-case review of individual incidents of use of force as well as more systemic review in order to identify patterns of incidents. LCJ shall incorporate such information into quality management practices and take necessary corrective action.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. However, the revised policy and procedure has not been implemented; therefore it cannot be evaluated in totality as of yet.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should be implemented. Security staff and supervisors should start receiving training on the Use of Force Policy and Procedure.
2. It is also my recommendation that all use of force incidents be reviewed by the Deputy Warden of Security and the Warden.
3. During my next review I will be reviewing use of force reports and the review process of use of force incidents.
f. LCJ shall ensure that Qualified Medical Staff request that inmates sign arelease of medical records for the limited purpose of administrative and investigative review of any incident involving an inmate injury. Q ualified Medical Staff will document the request and the inmate’s response. L CJ will ensure that inmates receive adequate medical care regardless of whether they consent to release their medical records.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
This provision of the SA is addressed in the revised Use of Force Policy and Procedure. LCJ staff and their consultants are working with Dr. Ron Shansky on ensuring that these requirements of the SA are met and are also addressed in medical policy and procedure.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the medical policies and procedures will also include these provisions of the SA and that both security and medical staff start receiving training on them.
g. LCJ shall ensure that management review of use of force reports and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical documentation of inmate injuries as reported by Qualified Medical Staff, including documentation surrounding the initial medical encounter, an anatomical drawing that depicts the areas of sustained injury, and information regarding any further medical care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policies and Procedures. RJS consulting staff are working with the medical staff in ensuring that the medical policies and procedures address these provisions of the SA as well.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ Staff should implement the revised Use of Force Policy and Procedure. 2. The medical policies and procedures should also contain the provisions of this
paragraph of the SA.
h. LCJ shall establish criteria that trigger referral for use of force investigations, including but not limited to, injuries that are extensive or serious; injuries involving fractures or head trauma; injuries of a suspicious nature (including black eyes, broken teeth, injuries to the genitals, etc.); injuries that require treatment at outside hospitals; and reports of events by staff and inmates that are inconsistent.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. It appears that some staff training has already been conducted regarding this provision paragraph of the SA. However, all staff need to be trained on it as part of the pre-service and annual in-service staff training program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should be implemented and all staff trained on it.
i. LCJ shall develop and implement a system to track all incidents of use of force that, at a minimum, includes the following information:
(1) a tracking number; (2) the inmate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:

These provisions of this paragraph of the SA have been incorporated into the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved, signed, but not yet implemented. The system to track all incidents of use of force has not been developed or implemented.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The revised Use of Force Policy and Procedure should be implemented.

2.

The system for tracking all incidents of use of force should be promptly

developed and implemented.

j. LCJ shall ensure that as part of a u se of force incident package, security supervisors shall ensure that photographs are taken of any and all reported injuries sustained by inmates and staff promptly following a use of force incident. The photographs will become evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA are contained in revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved and signed, but not yet implemented. There has been some training provided on these provisions to LCJ staff. It is too early to fully evaluate the provisions of this paragraph in the absence of the policy implementation and full staff training.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy should be implemented in order to be able to fully evaluate compliance with the SA.

k. LCJ shall establish an “early warning system” that will document and track correctional officers who regularly employ force on inmates and any complaints related to the excessive use of force, in order to alert LCJ administration to any potential need for retraining, problematic policies, or supervision lapses. Appropriate LCJ leadership, supervisors, and investigative staff shall have access to this information and monitor the occurrences.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT: An early warning system is addressed in the revised Use of Force Policies and Procedures. The revised Use of Force policy and procedure has been approved and signed, but

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not yet implemented. It is too early to evaluate the overall requirements of these provisions of this paragraph of the SA because the overall system is not yet developed and implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should be implemented. 2. Concomitant with the implementation of the Use of Force Policy and Procedure,
LCJ staff should start developing and implementing the early warning system described in the revised Use of Force Policy and Procedure.
l. LCJ shall ensure that a supervisor is present during all planned uses of force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
This provision is addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved and signed, but not yet implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should be implemented.
m. Where there is evidence of staff misconduct related to inappropriate or unnecessary force against inmates, LCJ shall initiate appropriate personnel actions and systemic remedies, as appropriate. L CJ shall discipline appropriately any correctional officer found to have:
(1) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or other staff member for reporting the use
of excessive force; or (4) interfered or failed to cooperate with an internal investigation regarding
use of force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. The revised Use of Force Policies and Procedures have been approved and signed, but not yet implemented.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the revised Use of Force Policy and Procedure be implemented so that full compliance can be evaluated with respect to discipline of staff that have used inappropriate or unnecessary force against inmates.
n. LCJ shall develop and implement accountability policies and procedures for the effective and accurate maintenance, inventory and assignment of chemical and other security equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedures address incapacitating agents, electronic control devices and the use of the restraint chair. T he procedure for the maintenance, inventory and assignment for the electronic control device is addressed in the use of force policy. However, the policy does not contain those controls for restraint equipment such as handcuffs and leg irons. However, LCJ maintains other policies and procedures governing all security equipment and are now cross-reference with the Use of Force Policy and Procedure and contain the specific provisions of this paragraph of the SA.3
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should be implemented.
o. Use of Force Training:
(1) LCJ shall develop an effective and comprehensive training program in the appropriate use of force.
(2) LCJ shall ensure that correctional officers receive adequate training in LCJ’s use of force policies and procedures.
(3) LCJ shall ensure that correctional officers receive adequate training in use of force and defensive tactics.
(4) LCJ shall ensure that correctional officers receive pre-service and inservice training on reporting use of force and completing use of force reports.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE

3 During the course of the inspection I noted that detention staff are required to purchase their own OC spray. I also noted that some officers carry OC spray that has expired. In most jurisdictions, the facility provides detention staff with all security equipment including OC spray. It is difficult for LCJ supervisors to maintain strict accountability and control of chemical agents when detention staff required and allowed to purchase their own OC spray. As the new Use of Force policy is implemented it will be difficult for LCJ to comply with the provisions of this paragraph of the SA under the current practice of OC spray issuance.

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ASSESSMENT:
The staff training provisions for the requirements of this paragraph of the SA are under development by Mr. Brad Hompe and were to be provided to the Sheriff by October 1, 2011.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should finalize their staff training program for the use of force that addresses the provisions of this paragraph of the SA and commence the implementation process.
p. LCJ shall ensure that inmates may report allegations of the use of excessive force orally to any LCJ staff member, who shall reduce such reports to writing.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. The revised Use of Force Policies and Procedures have been approved and signed, but not yet implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented.
q. LCJ shall ensure that Qualified Medical Staff question, outside the hearing of other inmates or correctional officers if appropriate, each inmate who reports for medical care with an injury, regarding the cause of the injury. I f, in the course of the inmate’s medical encounter, a health care provider suspects staffon-inmate abuse, that health care provider shall immediately:
(1) take all appropriate steps to preserve evidence of the injury (e.g., photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator; (3) adequately document the matter in the inmate’s medical record; and (4) complete an incident report.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedures has been approved and signed, but not yet implemented.

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RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented. 2. These provisions should also be addressed in the medical policies and procedures.
r. LCJ shall develop, assign, and train a t eam of specialized use of force investigators that will be charged with conducting investigations of use of force incidents. T hese use of force investigators shall receive at the outset of their assignment, specialized training in investigating use of force incidents and allegations.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policies and Procedures. T he revised Use of Force Policies and Procedures have been approved and signed, but not yet implemented. A use of force investigative team has not been developed, assigned or trained as required by these provisions of this paragraph of the SA.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should be implemented. 2. It is further recommended that LCJ officials develop, assign, and train a team of
specialized use of force investigators as required by these provisions of this paragraph of the SA.
s. LCJ shall ensure that incident reports, use of force reports and inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, that it is referred for investigation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures address the provisions of this paragraph of the SA. The revised use of Force Policies and Procedures have been approved and signed, but not yet implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented.

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THIRD COMPLIANCE REPORT LAKE COUNTY JAIL MAY 2012
A. MEDICAL CARE: Settlement Agreement Section III Part A.
1. LCJ shall provide adequate services to addr ess the serious medical an d mental health needs of all inmates.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
Leadership for the medical program at Lake County Jail has changed. Lake County has given a 1 year contract to Correctional Health Indiana (CHI). Dr. Forge is the Medical Director, Thomas Todd is the CHI Administrator and Deb Back is the Director of Nursing. This team was in place at the beginning of the contract in January of 2012. The contract is for personnel only. Supplies and equipment are provided by the Sheriff. CHI organizes and advises on specialty costs but the cost is paid by the Sheriff. Lake County also pays for pharmacy costs through a contract with In Touch Pharmaceuticals. CHI is asked to verify cost of pharmaceutical invoices.
This reconfigured program is engaged and performing well. Dr. Ron Shansky has been added to the consultant group of Ken Ray. Dr. Shansky will be extrem ely useful in assis ting Dr. Forge and CHI to complete policies, protocols and initiate steps to improve processes of clinical care at the Jail.
I discussed metrics which should be in pl ace and m onitored by a Quality Improvem ent Committee. These include:
 The length of time from intake screening to provider assessment by acuity status.  Percent of incarcerated detainees who receive intake screening.  Percent of incarcerated detainees who receive tuberculosis screening.  Number of health care slips picked up daily.  Number and percent of health care slips picked up which are triaged with 24 hours.  Number and percent of symptomatic complaints on health care slips w hich have a face -
to-face evaluation within 72 hours.  Average time from physician order to adm inistration of m edication for prescription
medication.  A no show report indicating the number of specialty, sick call, and provider appointments
who showed up and w ere seen as well as those who don’t show and the reason for no show. This should include percentages.
In addition to these metrics, the program should establish several quality metrics for clinical care as delivered by nurses and providers which should include chronic care visits and evaluation of health care slips.

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RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Develop metrics outlined above as part of a Continuous Quality Improvement Program.
2. LCJ shall d evelop and implement medica l care policies, procedures, and practices to address and guide all medical ca re and services at LCJ, in cluding, but not limited to the following:
(1) access to medical care; (2) continuity of medication; (3) infection control; (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; (11) comprehensive health assessments; (12) mental health; (13) women's health; (14) quality management; and (15) emergent response.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
All policies are s till in p rogress. C HI has had 3 m onths to hire staff, get the program up and running and in that tim e has begu n to settle in and develop th eir strategy for operating the program. Dr. Shansky has been engaged by Ken Ray to assist the m edical program in policy development, protocol development, and process improvement.
The team needs to focus on the 15 policies required in the Agreement. Writing policies needs to be followed by staff training and im plementation. In addition, there are several areas including medication administration, intake and infirm ary or special needs housing wh ich should result in combined custody/medical policies which describe responsibilities of medical and custody staff. Coordinating these processes between custody a nd medical and committing them to writing will establish rules for operations which will expedite attaining substantial compliance.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Develop key policie s relevant to this agreem ent and lis ted in Part A, item Agreement.
2. Ensure leadership involvement in policy development.

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3. Follow up policy development with training and implementation. 4. In key areas, have interagency policie s which coordinate custody and m edical
responsibility for certain processes: e.g., m edication administration, intake procedures, and special housing care or infirmary care.

3. Intake Screening and Health Assessments.

a. LCJ shall develop an d implement policies and proced ures to ens ure that adequate medical and mental health int ake screenings and health assessments are provided to all inmates within 14 days.

b. LCJ shall ensure that, upon admission to LCJ, Qualified Medica l Staff utilize an appropriate medical intake screening instrument to identify an d record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:

(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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any o f these items shall be referred for timely medical evaluation, as appropriate.

c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 days of h is or her arrival at LCJ sh all include a complete medical history, physical examination, men tal health history, and current mental statu s examination. The physica l examination shall be conducted by Qualified Medical Staff. Records documentin g the assessment and results shall become part of each inmate's medical record. A re -admitted inmate or an inmate transferred from anoth er facility who has received a documented full health assessment within the previ ous three months and whose receiving screenin g shows no change in the inmate 's health status need not receive a new full physical health assessment. For such inmates, Qualif ied Medical Staff sha ll review prior records and update tests and examinations as needed.

d. LCJ shall ensure that Qualified Medica l Staff attempt to elicit th e amount, frequency and time o f the last dosage of medica tion from ever y inmate reporting that he or she is currently or recently on medica tion, including psychotropic medication.

e. LCJ shall implement a medication continuity system so that incoming inmates' medication for serious medica l needs can be obtained in a time ly manner, as

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medically appropriate when medically necessary. Within 24 hours of an inmate's arrival at LCJ, or sooner if medica lly necessary, Qualified Medical Staff shall decide whether to continue the same or comparable medication for serious medical needs. If the inma te's reported medication is discontinued or changed, a Qualified Medical Profession al shall evaluate the inma te face-toface as soon as medically appropriate and document the reason for the change.

f. LCJ shall ensure that incoming inmates who presen t with curren t risk o f suicide or other acute mental health n eeds will be immed iately referred for a mental health evaluation by a Qualified Mental Health Professional. Staff will constantly observe suc h inmates until th ey are seen by a Qualifie d Mental Health Professional. Incoming inmate s reporting these conditions will be housed in safe conditions unless and until a Mental Hea lth Professional clears them for housing in a medical unit, segregation, or with the general population.

g. LCJ shall ensure that all inma tes at risk for, or demo nstrating signs and symptoms of drug and alcohol withdr awal are timely identified. L CJ shall provide appropriate treatment, housing, and medica l supervision for inmates suffering from drug and alcohol withdrawal.

h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.

i. LCJ shall e nsure that correctional of ficers supervising newly arrived inmates physically observe the conduct and appear ance of these inmates to determine whether they have a more immediate n eed for medical or mental health attention prior to or following the intake health screening by Qualified Medical Staff.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

3.a.

The policy on reception screening is still incomplete. I was shown a draft policy but a finalized product is pending. I discussed with medical leadership the acuity ranking system, how TB screening might be performed, and generally how the process of intake might function. I advised that if the organization utilizes the National Commission on Correctional Health Care (NCCHC) alternate standard for intake screening, they may be able to eliminate the 14 day assessment for healthy individuals. I recommend this alternative as it is a more efficient process which saves labor.

Currently, CHI has provided for nurse intake screening 24/7; this is working well and staff are performing well. However, the intake screening is still not performed under conditions of privacy as screenings are done in the lobby of the intake area. I was shown a floor plan of the proposed rehabilitation of an existing inmate waiting area which will provide 3 screening booths

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and an examination room which will provide privacy for screening questionnaires and examination if required. An additional examination room will be created out of an existing nursing office in the intake area. Currently there are no examination tables in the intake medical office. When inmates need an EKG, the inmate has to lie on the floor. This is unacceptable. These problems can be remedied easily and staff discussed solutions with me during the visit.

3 b. (1-7)

The existing medical intake form in electronic format is adequate for purposes of screening. One comment is that the electronic form is a little confusing at there are two questions involving medical history. The form asks what are the inmate’s current medical conditions and a second question asks what is the inmate’s medical history. These are both similar questions and are probably confusing to staff. If possible, I propose that this be consolidated to one question.

3 c.

As described above in 3 a., it is my opinion that utilizing the alternative NCCHC assessment standard, is optimal for this program. Though there is no policy yet for health assessments, there is a practice of assigning an acuity ranking to patients (1-5) with 1 being the highest acuity. This acuity is suppose to be documented in the intake screening document but there is no standardized location where it is to be documented and the EMR does not have a data field for this item. Acuity 1 means that the inmate is to be seen for a medical assessment the same day. Acuity 2 means that the inmate is to be seen for a medical assessment within 24 hours. Acuity 3 means that an inmate is to be seen for a medical assessment in 72 hours. Acuity 4 means that the inmate is to be seen by medical staff within 2 weeks and Acuity 5 was not defined for me. Acuity levels 1-3 are to contain all patients with chronic illness. I could not verify that this is occurring based on record review. This idea is fundamentally sound. Acuity rankings should be defined and placed into the standardized procedure for intake. When this is done training should occur for staff. After training, audits should focus on appropriate assignment by intake nurses, timeliness of provider assessments, and the quality of the assessments.

3 d.

There is a field in the EMR intake screening document which elicits medication history. Intake notes which I examined did have the medication history filled out. It is best if the intake procedures standardize the information that the intake nurse is required to obtain.

3 e.

When the nurse takes a medication history and discovers that a patient is on medication, the intake nurse is to call a provider who may give a verbal order for medication. I could not verify that the verbal orders were co-signed by providers and I could not verify that nurse orders for medication were all documented as verbal orders. I verified that orders for medication from intake were administered within 48 hours and some within 24 hours. The facility should have a goal of administering the first dose of medication within 24 hours. All verbal medication orders must be electronically signed by a provider. This procedure should be standardized into a written procedure as part of the intake policy and procedure.

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3 f.

Refer to Dr. Metzner’s report.

3 g.

There are insufficient questions to identify alcohol or other drug withdrawal on the screening EMR questionnaire. There is currently no actively used standardized procedure for drug or alcohol withdrawal. Furthermore, there is no identified location to house suspected persons with drug or alcohol withdrawal during a treatment phase. I recommended 3 items:

 A screening mechanism for intake nurses to use to uncover those at risk for withdrawal from alcohol or other drugs and to incorporate that risk assessment into the intake screening form.
 Identification of a place to house patients during a detoxification process.  A nursing and provider procedure for detoxification incorporating the CIWA and
COWS scales.

3 h.

The intake screening information is electronically incorporated into the medical record and all records were accessible to me upon inspection. There were a few problems with an inmate having two separate electronic records. This was confusing and a root cause analysis should be initiated to search for the problem and eliminate it.

3 i.

The intake process is not described in a standardized procedure. Due to the chaotic nature of this process, I could not verify the role of the correctional officer in this process. Officers from other jurisdictions can pressure health care staff to hasten the intake evaluation so that they can leave the facility. This may result in health care staff accepting inmates who should not be accepted into the jail. The responsibilities of the officers, including the roles of observation of inmates by officers prior to medical screening, should be codified in a standardized procedure.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The system should perform an acuity ranking sy stem so that those with serious medical problems are tim ely seen after intake screening. Providers should prioritize those detainees with serious m edical conditions. Th is should be codified in a standardized policy and procedure
2. I suggest performing the Mantoux skin test at intake to improve screening rates. 3. A standardized system of review of the intake evaluations should be put in place. 4. Privacy should be established for intake screening evaluations. 5. Standardized alcohol and opi ate withdrawal procedures should be developed and
synchronized with orders in the electronic r ecord. These procedures should be approved by the Medical Director and should be cons istent with standard ized treatment of withdrawal syndromes.

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6. CHI should work with the Sheriff to have an Interagency Intake policy and procedure which states the responsibilities of officers and medical staff in intake.
7. Verbal orders must be signed by providers and signature must be clear in the record.
4. Acute care.
a. LCJ shall provide adequate and timely ac ute care for in mates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will in clude timely medical appointments and follow-up medical treatment.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
4 a.
The policy on em ergency medical response and adm ission to hospitals is not completed. The policy should specify w ho is m aking clinical decisions. It should stipulate the respons e depending whether a physician, m id-level provider, nurse, or correctio nal officer is the perso n responding to the em ergency. There should be a log of urgent or em ergent responses. The policy should indicate what hospitals the Jail has arrangements with for care.
The hospital log is now in place; I m ade a few minor recommendations to staff. This log is generally satisfactory. It would be better if the log were maintained on an electronic spreadsheet.
There are still some problems with clinical care of people with acute problems. A woman with a threatened abortion and another male inmate with heart failure both ha d problems getting their acute problem addressed tim ely. These cas es were d iscussed with staff. These ca ses demonstrate that identification of patients by acuity and subsequent appropriate clinical follow up is still lacking. Another inm ate who presented through the inm ate card system wrote that he had an injured hand. Through a series of errors the inmate didn’t get a definitive evaluation for a few weeks.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. The policy and procedure on acute and emergency care must be completed. 2. Patients requiring hospitalization should have their clinical care at the facility evaluated
in order to identify any process or clinical quality issues wh ich are correctable. This can be part of the Quality Improvement program.
5. Chronic care.
a. LCJ shall develop and implement a writte n chronic care disease ma nagement plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.

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b. LCJ shall adopt and implemen t appropriate written clinical practice gu idelines for chronic and communicable diseases, su ch as HIV, hypertension, diabetes, asthma, and elevated blood lipids, cons istent with nationally accepted guidelines.
c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.
d. LCJ shall keep records of all care provided to inma tes diagnosed with chronic illnesses in the inmates' individual medical records.
e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evalua te the s tatus of their health and the effectivenes s of the medication administered for their chronic conditions.
f. LCJ shall ensure that in mates with disabilities or who need skilled nursing services or assistance with activities of daily living sh all receive medically appropriate care.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
5.a.
Chronic illness policies and proced ures are not com pleted and must be completed with training and implementation to follow.
5.b.
Clinical practice guidelines for chronic illness are not yet com pleted. Rather than re-inventing these, I rec ommend that the J ail utilize existing chronic illness gui delines used by other correctional systems and m odify these to acco mmodate unique issues at the Lake County Jail. Dr. Shansky will be able to assist in this effort.
5.c.
The status information sent to me from LCJ included a chronic illness roster. The roster is sorted by location and duplicates names of people who have more than one disease. The disease is not related to a diagnosis bu t to categories such as “general m edical” or “gastrointestinal” which do not assist clinical staff in prioritizing appointm ents. There is not yet a consistent roster which lists patients with their a ssociated disease. The chronic illness roster is manually derived from CorrectTek information. Data is dumped into a spreadsheet and manipulated. But this data is defective because it is incompletely or inaccurately entered.

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Staff, including management staff, remain confused as to how to use CorrectTek to enter problems. It remains to be seen whether this software is capable of doing what staff expect it to do. CorrectTek must satisfy the needs of clinical staff and the Jail to obtain necessary data. If the software works, then additional training is indicated. If the software does not work, then the Jail should consider other software. The requirement should be that all patients with a chronic illness have a data element in the medical record identifying their illness and this data must be able to be placed into a list. Inactive patients must be excluded from the list. The acuity ranking of disease should be a data element.
In sum, the current chronic care roster is deficient for several reasons.
1. The roster is m anually derived from CorrectTek and a variet y of sources and it appears that many errors exist. It is not clear if th is is because CorrectTek is deficient or because staff is not using the software properly.
2. The providers are inconsistently entering the problem into the EMR in a manner which allows for data capture. W ithout this happeni ng, the search of the EMR is not able to produce an accurate list of persons with chronic illness and patients will be missed.
3. The system has not con sidered chronic illness for uncommon illnesses such as collagen vascular disease, valvular heart disease, or cancer. As a result, persons with a serious but uncommon illness will not be found on the chronic illness roster and are at risk for being lost to follow up.
4. The disease of the patient is not listed. This is important because staff who are using the list to identify high risk patients will be unable to do so. If a person with Chron’s disease is listed as “Gastrointestinal” then one cannot differentiate someone with Chron’s disease which is serious, from someone with reflux disease which is not serious.
5. The acuity of the patient is unavailable.
5.d.
Though CorrectTek is difficult to use, it does keep a record of care provided, including medication administration and provider visits. Chronic illness visits are not identified as such in the electronic record but I could acceptably navigate through the chart nevertheless.
5.e.
CHI has hired a chronic illness nurse who is tas ked with tra cking persons with chr onic illness and ensuring that necessary diagnostic testi ng, monitoring, and treatm ent is accomplished. She has developed a tracking spreadsheet but has ha d difficulty in iden tifying the en tire panel of inmates with chronic illness for the reason s specified in the previous para graph. Nevertheless, her work is valuable and will become more effective when the policy, procedur e, protocols and chronic illness roster are completed.
Patients with chronic illness are identified at intake and schedul ed for provider appointm ents based on an acuity ranking. Afterwards, the provi der re-schedules the patient at intervals determined by protocol. The scheduling interval is determined solely by the schedule as ordered

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by the provider. The new protocols should stipul ate minimum intervals. Medication renewal of persons with chronic illness is not yet standardized in a procedure.
Labs are perform ed by a vendor, CareEvolve, but lab data is not in terfaced to CorrectTek. Results are scanned into CorrectTek. This is not good because the laborato ry data is not easily accessible or able to be used in monitoring disease prog ress. The protoco ls should indicate intervals for routine blood testing or other testing.
Review of medical records of persons with ch ronic illness still dem onstrate missing diagnoses, dropped appointments, follow up errors, an d lack of continu ity. As part of the Quality Improvement program, medical leadership should review samples of at-risk ch ronic illness patients to test the performance of the system and chronic illness program.
5.f.
There is no infirmary in the jail. The 4 th floor of the old jail is considered medical housing. However there is no program of identification or management of inmates with special medical needs, including disabilities, or those requiring skilled nursing. The Jail will need to identify a location where such inmates can be housed and then establish policy and procedure for managing such a unit.
In review of the 4th floor housing unit, it was not possible to identify which patients were mental health or medical. Numbers used to identify m edical patients on a ro ster were not all accurate and signs to identify mental health patients were not all accurate. It wasn’t clear what illnesses patients had and what their plan of care was. This is a major problem area of concern and m ust be corrected.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Policy and procedure and clinic al guidelines for chronic i llness management and special needs management must be developed.
2. Management of chronic illn ess should begin in intake with identification, acuity ranking and appropriate referral to a provider.
3. Transportation issues involving getting patients to clinics must be resolved. 4. The providers m ust use a standardized m ethod of recording problem s in the electronic
record which permits maintaining a roster of persons with chronic illness. 5. Physicians must m anage chronic illness by seeing patients at appropriate intervals,
renewing medication, and perfor ming thorough evaluations pertinent to the chronic disease being managed. 6. Lab and other testing (EKGs) should be performed as indicated by appropriate guidelines at indicated intervals. This information should be interfaced with the EMR. 7. A system of m anagement of patients with disabilities and serious m edical problems equivalent to infirmary care must be established. Such a system would include:
a. Admission by a physician b. Tracking of these 4th floor patients by name and diagnosis c. Acuity ranking of patients

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d. Defined interval evaluations by nursing and medical staff e. Rules for management of types of patients f. Rules for who can be admitted to the unit g. Discharge criteria h. Discharge only by a physician i. Complete access to physicians j. Adequate nursing coverage k. Physical space that accommodates ADA type patients l. A manual of care for nurses on the unit
6. Treatment and Management of Communicable Disease.
a. LCJ shall develop and implement adequat e testing, monitoring, and treatment programs for management of communicabl e diseases, including tu berculosis ("TB"), skin infections, and sexually transmitted infections ("STIs").
b. LCJ shall develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, in cluding TB, skin i nfections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
c. LCJ shall continue to test all inma tes for TB upon booking at LCJ and follow up on tes t results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LC J shall follow current CDC guidelines for management of inmates with TB infec tion, including pr oviding prophylactic medication when medically appropriate. If directed by a physician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.
d. LCJ shall ensure that any negative pr essure and ventilation sys tems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. LCJ shall docu ment results of such testing.
e. LCJ shall d evelop and implement adequat e guidelines to ensure tha t inmates receive appropriate wo und care. Such guidelines will include precautions to limit the possible spread of M ethicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.
f. LCJ shall adequately maintain statis tical information regarding communicable disease screening programs and other re levant statistical data necessary to adequately identify, treat, and control infectious diseases.

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OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

6.a.

CHI has hired an infection control nurse. This nurse is actively engaged in starting an infection control program, but the leadership is inv estigating the specific requirements of a corre ctional infection control program. There is significan t energy and exce llent morale in this ef fort. I suggest that rather than reinvention of the a de novo program , CHI work with Dr. Shansky to obtain material from other jail program s and Centers for Disease Control docum ents to modify for their use.

6.b.

The infection control policy and procedure and the infection control manual are still be ing developed. Again, I recomm end utilizing exis ting policy, procedures, m anuals and other standardized procedures from other systems and modify rather than produce these de novo.

6.c.

Written policy and proc edure in conformance with the Ce nters for Disease Contr ol (CDC) TB

guideline has not yet been written.

The CDC reference can be found at

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm. The main purpose of tuberculosis

screening is to prevent an inf ectious person from gaining adm ission to the general population of

the Jail. There is a temptation to establish a procedure to reduce the nu mber of people screened

by waiting for the latest date possibl e to screen. This would not be in keeping with the intent of

the established CDC standard. In this regard, CHI should draft guidelines and then meet with the

State Health Department to review and obtain approval for these guidelines.

The current practice at LCJ is to perform TB symptom screening a t intake. All inm ates who remain incarcerated 24-72 hours are given a Mant oux skin test. But the m edical assistant who does this only plants tests Monday through Thursd ay because she is off weekends. Thus, there may be a delay of 3 days every week when people are not screened. As well, the burden of tests to be done on Mondays m akes it difficult to perform. These barriers result in reduced screening numbers.

The infection control nurse is st arting to keep d ata on TB screen ing. F or the recen t 3 m onth period, 3415 inm ates were incarcerated in the ja il but only 924 (27%) were screened for TB. The medical team implied to me that most people leave the jail before they could be screened but I could not verify that 73% of those incarcerate d leave the jail with in a week. These data m ay mean that inmates remain unscreened for weeks.

My suggestion is to place a Mantoux skin test upon intake admission and read it within 72 hours. This would permit intake nurses to test every incoming inmate and for th e medical assistant to

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focus entirely on reading tests. This will increase the number of persons screened and will result in earlier screening.
6.d.
There is no negative pressure ventilation system at the jail. The jail has a stated practice of placing an N-95 respirator on any individual identified as suspic ious for having tuberculosis. The stated practice is transfer to a local hospital for evaluation. This stated practice needs to be developed into a written standardized policy and procedure.
6.e.
Wound care and MRSA guidelines do not now exist. As with other policies, I recomm end utilizing documents from other jails and m odifying to accommodate c onditions at the Lake County Jail. Dr. Shansky can be helpful in this process.
I did identify on chart review of inm ate health requests that inmates with skin lesions consistent with MRSA inf ection were not timely evaluated. So, improve ments can b e made when an appropriate procedure is implemented.
I reviewed the 2008 report from the State Board of Health regarding the MRSA outbreak at the jail. Their recomm endations should taken into consideration in developm ent of the inf ection control policy and procedure and infection control manual.
6.f.
A nurse is now assigned to infectio n control. Surveillance data is m odified from data taken from correctTek but getting standa rdized data has been difficult. Manual deri vation of data is still done and this is subject to error.
For MRSA surveillan ce data, the inf ection control nurse is bas ing reports on po sitive culture results and contac t isolation lists. Many fals e positive reports occur because intake nurses in intake are reporting any sk in rash as a presumptive MRSA in fection. On th e other hand, the infection control nurse never hears about the multitude of patients presumptively treated for MRSA who do not undergo culture. Surveillance n eeds to be based on actual and presum ptive MRSA cases and should include provider referra l of presum ptive cases. The purpose of surveillance is so that the jail will know when clusters of presumptive MRSA cases exist so that the Sheriff can app ropriately sanitize the jail a nd can effectively contro l MRSA transm ission. The surveillance data should include type of le sion, whether discharge wa s present, whether the patient was treated and culture result. Results should be sent to Quality Improvement.
For influenza, there is no surveillance data now captured.
For tuberculosis, surveillance c onsists of skin testing and is done. As m entioned above, only 27% of inmates are screened. Surveillance data should be consistent w ith CDC requirem ents. This requires annual employee testing and conve rsion rates for e mployees. Suspicious and

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active tuberculosis cases should also be tracked.

Finally, it would help is the infection control nurse was working from a standardized procedure for collection of infectious disease data. Th is is best established by developing a surveillance dataset which was reviewed with the State and Local Department of Health.

RECOMMENDATIONS FOR NEXT 6 MONTHS:

1. Develop an infection control plan that

includes tuberculosis screening, MRSA

management and influenza m anagement. Th is plan should also include Occupational

Health and Safety required blood borne pathog en practices and isol ation procedures in

the event of an airborne contagious disease event.

2. Develop treatment guidelines for MRSA, tuberculosis.

3. Develop vaccination procedures for influenza.

4. Develop airborne isolation procedures consistent with Centers for Disease guidelines.

5. Establish surveillance tracking of tuberculosis, skin test rates, conversion rates, employee

conversion rates, and MRSA rates,

6. Establish physician oversight over infection control issues.

7. Involve the State Departm ent of He alth and Local Department of H ealth in review and

acceptance of the Infection Control policy, procedure, and manual.

7. Access to Health Care.

a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.

b. LCJ shall ensure that the medical requ est ("sick call") process for inmates is adequate and provides inmates with adequate access to medical car e. The sick call process shall include:

(1) written medical and mental hea lth care slips available in Englis h, Spanish, and other languages, as needed;
(2) a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week;
(3) opportunity for illitera te inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and
(4) opportunity for all inmates, irresp ective of primary language, to access medical and mental health care.

c. LCJ shall ensure that the sick call process includes lo gging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation of th e date and summary of ea ch request for care, the date the in mate was s een, the name of the p erson who saw him or her, the disposition of the medical or mental he alth visit (e.g., referral; whether inmate scheduled for acute care visi t), and, if follow-up care is necessary, the date and time of the inmate's next appointment. LCJ shall document the reason for and

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disposition of the medical or mental health care request in the inmate's medical record.
d. LCJ shall develop an d implement an e ffective system for screenin g medical requests within 24 hours of submission. LC J shall ensure sick call requ ests are appropriately prioritized based upon the seriousness of the medical issue.
e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
f. LCJ shall ensure that there is an adequate number of correctional officers to escort inmates to and from medic al units to ensure that inmates requiring treatment have timely access to appropriate medical care.
g. LCJ shall ensure that Qualified Me dical Staff make d aily rounds in the isolation areas to give inmates in isol ation adequate opportunities to contact and discuss medical and mental he alth concerns with Qualif ied Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medica l Staff will ass ess inmates for new clinical findings, such as deterioration of the inmate's condition.
h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care will be provided regardless of the inmate's ability to p ay. No fee -for-service shall be required fo r certain conditions, including health screen ings, emergency care, and/or the treatment and care of condition s affecting pu blic health, e.g., Tuberculosis, MRSA, pregnancy, etc., particu larly for in digent inmates who are not covered by a health insurance plan or policy.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
7.a.
Significant progress has been initiated toward obt aining compliance with this item . However, for all the reasons listed belo w, a considerable am ount of wo rk remains to be done. In accordance with the Ag reement, the Jail m ust develop a standardized policy and procedure for this process. My suggestion is that in conjuncti on with development of a medical procedure, the medical program work with custody on an inte ragency procedure for handling and managing the health call request process.
Based on requirem ents of the Agreem ent, the po licy, procedure and interagency arrangem ents must include the following:

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 Confidentiality of collection 7 days a week  Slips with Spanish and English language  Method of access for cognitively impaired and illiterate  A methodology for tracking timeliness of triage and follow up.  Description of where the patient would be triaged, have face-to-face evaluations and
where follow up would occur.  A methodology for prioritization of slips based on medical seriousness  A method to track patients not brought for evaluation by custody so that transportation
processes can be monitored.
7.b.
The current system of inm ates making medical requests utilizes an “inm ate medical card”. These pieces of paper have room for the deta inee to write the ir complaint but n o space for clinical staff to write their ev aluation. The he alth care staff section is very sm all and only has room to write the date received, triaged and a sm all line to indicate a response. This response line is inadequate as a clinical respo nse. However, the “card” is adequate provided that nurses write their response in the m edical record. If this is done, there must be a way to correlate the request with the nurse note. In chart review it was extr emely difficult to co rrelate a nurs e progress note with a specific inmate medical card.
The current system of access is s till deficient in that it is not avai lable to all inmates. “Medical Cards” are not available in Spanish or other languages and I could not ve rify any mechanism for the cognitively impaired or illiterate to access health care. I would suggest using a service by AT &T for telephonic language interpretive services which is priced on a use basis.
7.c-d
A log is m aintained which has the d ate submitted, the date c ollected and triaged, the name, the complaint, the disposition, the acuity level, the people who had the 72 hour evaluation and appointment date. The nurse collects all slips daily M-F. When she is off or when someone calls in, sick slips are not collected that day. For March there were five days when no slips were collected. There is no face to face on Saturd ay and Sunday. So there is a larg e volume on Monday AM. The sick call nurse estim ated that there might be 30 m edical requests a day. Because officers are available to transport patients only on a limited basis and only between 7:30 AM to 10:30 AM and again from 12:30 PM to 2:30 PM, the single nurse only has 5 hours a day to perform face-to-face evaluations. As a result there are more patients to be seen than can be seen in a day and the excess is m erely referred to a prov ider clinic without a nurse evaluation. The result is that m ost inmates in the provider c linic leave the facility before anyone sees them for their complaint. Eventually, this will result in mistakes. Staff related to m e that a parallel sick call process has developed in which inm ates with urgent com plaints contact officers who bring them to the clinic as urgent visits. Th is has probably developed b ecause the routine sick call process is not able to process requests timely.
The actual process of evaluating slips consists of the nurse verifying in CorrectTek that there are no duplicate requests for that inm ate. The f act that there are m any duplicate requests i s

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testament that the sick c all process is still broke n requiring multiple r equests before being seen. For non-symptomatic cases, the nurse just addresses the concern by discussing the issue with the detainee; for non-sym ptomatic request this is adequate. For symptomatic requests the nurse addresses only the most critical requests and refers the others to the clinic.
Face-to-face encounter notes are w ritten as “s ick call docum entation” or “sick call” notes. Triaging notes are only written on the sick call slip and there may be no docum entation in the record. The face-to-face encounter dates are not documented or tracked. The number referred to provider is not tracked. The number reviewed entirely by a nurse is not tracked. Nurse oversight and review is not now being done. When staffing is short, sick call requests are not done.
7.e.
Nurses still perform some face-to-face evaluations cell side. Given that there are 3-4 clinic exam rooms dispersed throughout the jail for the pur pose of sick call evaluation, there is probably adequate space for this process. However, b ecause there are in sufficient officers to brin g inmates to these rooms, nurses still go to tiers to see inmates.
7.f.
There is general agreement that there are insufficient officers to transport inmates for scheduled appointments for nurse evaluation as well as for m edical clinic. As a result inadequate num bers of inmates are seen for requests. I spoke with the transportation officers. Officers who transport inmates get a list daily from the m edical staff for all inm ates who need to be transpo rted to clinics for sick call or provider visits. These lists have the m edical reason for visit and m ay include diagnostic inform ation. This should be discontinued as it is a HIPPA violation. The transportation officers, based on the number of available officers, prioritize the inmates they will bring to clinic based on the information on the s heet. The o fficer I spoke to indicated that only about 20-40% of inm ate could be brought to thei r appointment on a daily basis. Those inm ates not brought are rescheduled. However rescheduli ng into an overcrow ded schedule results in a steady state of inmates not being able to access care because they will be discharged from the jail before they can be seen.
7. g.
Medical staff do circulate in segregation areas. They document their presence on the tier in a tier log maintained by custody staff. I checked th e log for one week in March. On five days there was a notation that medical staff were present on the unit; two days there was no docum entation of segregation rounds. When I toured the unit, I asked several inmates if nurses came by to ask if they had problems and all three inmates I asked indicated that nurses do come by to ask if they have problems.
7. h.
Lake County Jail has a co-pay po licy which requires a $10 paym ent for evaluation of sick call requests as well as doctor visits. Effectively, this policy is not enforced. Under the cu rrent

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circumstances, I agree with not enforcing this policy. Since the process is broken and the system can not effectively process requests or schedule inmates for tim ely visits, adding a financial component to this dysfunction would only exacerbate the problem.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Sick call policy and procedure must be developed. 2. Sufficient staff should be available to evaluate all slips. 3. Transportation issues involving getting patient to the clinic must be resolved. 4. Nurses should triage all slips within 24 hours. 5. Emergent issues must be addressed immediately. 6. Slips that in clude symptoms must include a nurse face to face evalu ation in a clinical
setting. This should occur no later than 72 hours based on the clinical issue. 7. A system of tracking requests should be maintained. 8. A way to d ocument a face to face evaluation by nursing should be established in the
medical record that associates with the medical card in question. 9. The “Inmate Medical Card” should be revised to include:
a. Mental health requests b. Dental requests c. A space to date the day the card was received by medical and the date triaged by a
nurse d. A space for a nurse to write a brief triaging note. e. Typical complaint types 10. Metrics should be instituted in the Quality Improvement program to include: a. The number of requests picked up daily b. The number of slips triaged within 24 hours c. The number of slips with symptoms that had a nurse evaluation within 72 hours. d. The number of slips referred for provider evaluation. 11. A monthly nurse quality evaluation should include supervisory review of a select number of nurse evaluations to ensure adequate quality. 12. All nurse evaluations should include vital signs. 13. Nurse protocols for evaluations should be developed. These m ust be approved by the Medical Director. 14. Officers must not be involved in prioritizing patients to bring to clinic off a schedule list. Any prioritization must be performed by medical staff. 15. Officers must not be in possession of sche duling lists which include protected health information.
8. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates w ho receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimu m, discharge instructions are obtain ed, appropriate Qualified Medical Staff reviews the

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information and documentation available from the vis it, this review and the outside provider's documentation are recorded in the in mate's medical record, and appropriate follow-up is provided.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
8. a-b.
The policy or standardized procedure is not yet in place. There is a practice that is in place but it is not standardized and different staff I spoke w ith gave different interp retations of what is occurring. All inm ates returning from off site m edical visits (specialty vi sits or hospitalization) are supposed to go to the intake area for evalua tion. This is a sound concept. However, the documentation which is to occur is not consistent. Nurses in intake I spo ke with completely redo another intake screening. Management staff did not understand that this was occurring. If the intake form is re-done, ostensibly any new me dications would be pick ed up and the patient would be assigned another acuity assignment, but I could not verify that this occurs. I could also not verify that upon return from the hospital, patients were timely evaluated.
It is a good idea to have all inmates returning from off-site appointment (specialty visit, ER visits and hospitalizations) return to the jail through intake. However, the intake nurse must work off a standardized procedure for these individuals. I would not perform another intake evaluation for people returning from off-site appointm ents or hospitalization. Instead, the nurse should evaluate the patient, and consul t a provider for any change in c ondition or change in therapy in order to obtain a new provider or der for treatment. A pro vider must be consu lted to renew medication including ordering any new therapy which was prescribed by the hospital or specialty doctors. A follow up appointment must be scheduled at an interval consistent with the condition of the inmate.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Upon return from the hospital or off- site consultation, all patients should go to a standard central location and be evaluated by a nurse and physician. If a physician is not present, the nurse should evaluate the patient and c onsult with a physician regarding any change in therapy. This discussion should be documented in the medical record.
2. The patient should be scheduled for a follow up physician visit to discuss and evaluate disease status.
3. For quality purposes, the log s hould be evaluated monthly to assess whether follow up is occurring as indicated.
4. The inmate must be evaluated for renewal of medication or change in therapy based on the outside visit. The nurse must consult with a physician for these orders.

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9. Emergency Care.
a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health n eeds receive timely and appropriate care, including prompt referrals and transpor ts for outside c are when medica lly necessary.
b. LCJ shall train all co rrectional officers to provide first responder assistance (including cardiopulmonary resuscita tion ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide a ll correctional officers with the necessary protecti ve gear, including masks and gloves, to provide first line emergency response.
OVERALL COMPLIANCE STATUS: Partial Compliance
ASSESSMENT:
9.a.
87 of 158 officers (55%) have been trained in health em ergencies and CPR. I would ask that Ken Ray send me a set of training material used for this course.
9.b.
I randomly checked the control stations on the 3 rd floor of the new jail and 3 rd floor south of the old jail. Both areas had a first aid kit including masks and gloves.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Medical Director should develop a trai ning module for custody staff to include serious medical conditions and blood borne path ogen issues. I ask that Mr. Ray send the latest electronic version of this training material.
2. Officers should be trained and their training should be verified in a tracking log.
10. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical an d mental health needs of inmates a t LCJ.
b. LCJ shall develop and implement p olicies, procedures, and practices to ensure timely responses to orders for medications and laboratory test s. Such policies,

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procedures, and prac tices shall be periodically evaluated to ensure time ly implementation of clinician orders.
c. LCJ shall ensure that medical a nd mental health reco rds are centraliz ed, complete, accurate, readily accessible, and systematically organized. All clinical encounters and review s of in mates should be docume nted in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out of LCJ for medical care. LCJ shall obtain records of ca re, reports, and diagnostic test s received during outside appointments in a time ly fashion a nd include such reco rds in the inmate's medical record or document th e inmate's refusal to cooperate and release medical records.
e. LCJ shall mainta in unified med ical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
10.a.
There is an electronic record in place but staff find it difficult to use. It is not clear to me whether this is a tra ining issue o r a proble m with the record itse lf; it isn ’t clear whether management staff are clear on this issue either. The interface with pharm acy has improved and is considered resolved. However, several areas of concern remain which will be discussed in the pharmacy section. On a few records I reviewed, th e provider orders did match with orders in the Medication Administration Record. However, nurses are still capable of ordering m edication and I could not verify that physician co-signature is occurring. The organization has performed 8 hours of training of all CHI staff when the cont ract started in January of 2012. New em ployees get on the job training but they s hould receive the same 8 hours of training. This also should be done for all mental health staff. CHI does have a data analyst to assist cl inical staff in obtaining data from the electronic record. T his is a pos itive development. This person sho uld work to obtain metrics used to m easure performance in the Agreement. There is a support line that is available for staff to call in th e event of a problem. We called the number and did get a prom pt response from an operator. This call num ber should be evident on a sign at stations where there is a computer. There is a down-time practice, but it is not standardized into a procedure and this should be done.
10.b.
Policies and procedures on timely responses to orders for medication and laboratory tests need to be developed. These should include physician co-signature for verbal orders.

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10.c.
An electronic record is in use. Medical prov iders do have access to th e record and the record is accessible to nurses as they adm inister medication. Labo ratory results are no t electronically interfaced with the record which is a problem . Encounters appear to be able to be entered into the record.
10.d.
I did not evaluate whether patients going to outsi de providers include appropriate infor mation to that provider. However, for inmates going to outside providers the facility does make an attempt to obtain records of the outside visit. Many reco rds do have a summ ary of the outside visit, but this is not consistently obtained. Records of outside specialty visi ts are particularly absent. For example, when pregnant fem ales go to the o bstetrician a record of that visit is not in th e electronic record. The Hollister or som e similar summary of treatment and evaluation should be present in the jail record so that the jail providers know what happened at the specialty visit.
10.e.
The electronic record is unified but is not completely electronic. Some elements are scanned into the record.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. An interface with the laboratory vendor should be put in place. 2. Software training should occur when new employees start work. 3. A system of tracking software issues shoul d be instituted to en sure that software
problems are solved. 4. A manual back up system should be in place in the event the software goes down.
Instructions in the event of software cr ashes should be docum ented in a “down time procedure”.
11. Medication Administration.
a. LCJ shall ensure that inmates r eceive necessary medications in a timely manner.
b. LCJ shall develop policies an d procedures to en sure the accurate administration of med ication and maintenance of medication re cords. LCJ shall provide a systematic physician review of the use of medica tion to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
c. LCJ shall ensure that medicine admin istration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distributionn.

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d. LCJ shall ensure that medication ad ministration is per formed by Qualified Nursing Staff who sh all administer prescription medications on a directlyobserved basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications withou t a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.
e. When LCJ has advance notice of th e discharge of inmates with serious medical or mental health needs, LCJ shall prov ide such inmates with at leas t a sevenday supply of appropriate prescription me dication, unless a different amount is deemed medically appr opriate, to s erve as a bridge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the pe riod of trans it for inmates who are being transferred to another correctional facility or other institu tion. LCJ shall prepare and send with transferring inmates a transfer summar y detailing major health problems and listing current medications and dosages, as well as medication history while at LCJ. LCJ shall ensure that infor mation about potential release or transfer of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a for mal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelin es for the prescrip tion of certain types of medications.
g. LCJ shall ensure that Qualified Medica l Staff counsels a ll patients who refuse medication.
h. LCJ shall secure the me dication room and disconti nue allowing food to be stored in the medication refrigerator.
COMPLIANCE ASSESSMENT: Partial Compliance
ASSESSMENT:
11.a.
On chart review, medications appear to be adm inistered within 48 hours; som e within 24 hours. The goal should be 24 hours from order. For some orders, no m edication arrives from the pharmacy resulting in a couple hours a day per nurse of reconciliation work. Nurses maintain a large stock of medication to use in the event th e medication does not arrive from the pharmacy. The pharmacy vendor, management and I had a discus sion on this issue. One solution m ay be a daily delivery of medication which has the po tential to red uce reconciliation issues. This will however, stress the ability of the pharm acy to produce non-for mulary medication. There will need to be a process for the facility to expe ditiously approve non-formulary medication so that pharmacy can quickly dispense it.

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There isn’t a standardized medication renewal process. This should be co ordinated with chronic clinic activity.
11.b.
There are no policies or procedures available on this item yet. The re is an existing medication renewal practice but it is not established in a wr itten procedure. Based on conversations with various staff, there appear to be a variety of wa ys that medication gets renewed. This should be standardized.
11.c.
I observed medication administration. Overall, this item is properly performed. However, I have a couple of comments. One is that there shou ld be an interagency policy and procedure on medication administration that specifies the responsib ilities of officers as well as nursing staff. The nursing responsibilities should include the 5 rights of m edication administration in the procedure. A second comment is that the nurses are verifying the correct medication compared to the MAR entry prior to m edication delivery. Th en the medication is placed in an envelope. When the nurse goes to the unit, the identification of the inmate is confirmed but the nurse then takes the pre-verified envelope of medication and administers to the inmate. This is a version of pre-pouring. I would say that this is an accepted but not r ecommended procedure. It is recommended that verification of the right medication should be m ade at the tim e it is administered. This can easily be done because the nurse has the m edication administration record available.
11.d.
Medication administration is mostly performed by medical assistants. These individuals all have a certificate on file. I have not yet verified that medical assistants can administer medication and it would be helpful if the Director of Nursing could provide that docum entation. Nursing staff do take verbal orders from physicians. When this occurs, documentation of that verbal order has to be in a progress note which I did not consistently find. As we ll, I could not find evidence of physician co-signing of verbal orders.
11.e.
LCJ does not now provide 7 days of medication to inmates who have se rious problems who are discharged. An acceptable policy, procedure and practice needs to be established.
11.f.
There were m eeting notes from a Pharm acy and Therapeutics Comm ittee and that group has established a preferred pharmacy list. Sustaining this Committee needs to be evidenced.

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11.g.
Currently, nursing staff do not have a written standardized process of addressing m edication refusal.
11.h.
There are two room s where m edications are store d. In one of these room s, there is a tiny narcotics box which does have a lo ck on it. That box is jam med full of medication. It needs to be larger and the utilization log readily availa ble in the box. There is a significant quantity of stock on hand because provider o rders do not alwa ys arrive timely from the pharm acy. Nurses therefore need a supply of drugs s o that they ha ve medication to complete the order. It is promising that the pharmacy vendor is working closely with CHI to remedy this problem.
There is not a good location to stor e medication carts, so they are still kept in a central area which is a m ajor walkway in the health c are unit. This leaves m edications on the cart in view and access to individuals walking through that area. A better arrangement is recommended.
RECOMMENDATION FOR NEXT 6 MONTHS:
1. The quality committee should develop a m echanism to establish the av erage time from prescription to delivery of medication to the patient.
2. Policies and procedures must be developed for medication administration and storage of medication. Staff m ust receive regular training on these po licies and procedures. In addition to the m edical medication administration policy, there should be an interagency procedure which specifies the responsibilities of custody and medical staff in medication administration.
3. Medication administration must be standardized. 4. The procedure for handling refu sals of medication must be standardized and developed
into policy and procedure. 5. Storage of medication carts should be in a secured area, away from civilians and inmates. 6. Medication renewal should include evaluation of the patient.
12. Medical Facilities.
a. LCJ shall ensure that sufficient clinical space is ava ilable to prov ide inmates with adequate medical care services including:
(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric
and pregnant inmates).
b. LCJ shall ensure that medical areas are adequately cleaned and m aintained, including installation of adequate lighting in medical exam rooms. LCJ shall

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ensure that hand washing statio ns in medical areas are fully equipped, operational and accessible.
c. LCJ shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including sy ringes and sharp medical tools) and hazardous waste.
d. LCJ shall provide for inmates' reas onable privacy in medical care, and maintain confidentiality of inmates' med ical status, subject to le gitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
12.a.
Sufficient space still does not exist to perform in take screening, physical assessments, and acute, chronic or s pecialty care. There is sufficient space for nurse sick call on the vario us tiers bu t there are insufficient officers to present inm ates to the nurses. The jail has a plan to renovate a room in the intake area to create an adequate space and I loo ked at the space and drawing. These appear sufficient. The existing clin ic space on the 4 th floor is unacceptable as is. I discussed some options with th e health ad ministrator. Also, Am erican with Disabilities Act (AD A) accommodations for disabled do not appear to be available on the 4th floor housing units.
The dental unit is unacceptable. There is no water for dental in strumentation and the dentist has his assistant utilize a sy ringe to squirt water in the patient’s m outh during procedures. This is primitive. The compressor is located immediately next to the dental chair creating an extremely loud work environment which is unacceptable. An electric junction box is located immediately next to the dental chair and that junction box is located over a sewer drain. Periodically, when inmates plug up toilets on the floor above, raw sewage spills out from this drain into the clinc and onto the electric junction box. This is unsaf e. There are no instru ments for restorative procedures. This unit needs to be reconfigured as a minimally contemporary dental unit.
12.b.
The medical areas that are used were clean and equipped with the exception of the dental unit.
12.c.
This item was not reviewed.
12.d.
Privacy of care s till does not ex ist in inta ke or in th e clinic arrangement on the 4 th floor. Remedial measures were discussed.

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RECOMMEDNATIONS FOR THE NEXT 6 MONTHS:
1. An evaluation room for medical and mental health intake evaluations must be established which permits for both security and privacy concerns.
2. Adequate clinical examination rooms need to be built for sick call request evaluations by nurses and for routine clinic examinations by providers.
3. Develop a plan for medical and mental health infirmary care housing. 4. Remedy the dental clinic situation.
13. Specialty Care.
a. LCJ shall ensure that inmates who se serious medical or me ntal health needs extend beyond the serv ices available at LCJ s hall receive timely r eferral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialt y care provider are scheduled for timely outside care appointments and transported to their appointmen ts. Inmates awaiting outside care s hall be se en by Qualif ied Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ shall mainta in a current log of all inmates who have been referred for outside specialty care, including th e date of the referral, the date the appointment was scheduled, the date th e appointment occurred, the reason for any missed or delayed appointments, an d information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmate s are provided adequate pre-n atal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregn ant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
13.a-b.
There were billing issues involvi ng many specialty providers who se rviced inmates at the jail. As a result, many providers refused to continue to see jail patients. It is easy to get appointments for Infectious Disease, Obstetri cs, Orthopedics, and Oral Surger y. H owever, it is difficult to obtain other consultations. One example was a patient needing a nephrology appointment which was ordered on March 12th. As of May 1st the patient still did not have an identified appointment

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and a provider willing to see him can not be lo cated. Dr. Forge is working on im proving these relationships and I was told that the billing issues have been resolved. Because of the manner of tracking specialty appointments, the system can not verify the length of time it takes to obtain specialty appointments. If an a ppointment is canceled it is resc heduled. When rescheduled, it appears as if the appointment is ordered at the time of the reschedule. This needs to be corrected so that the medical staff can identify the length of time an appointment is pending.
The procedure for specialty appoint ments is not com pleted. It will need to include a m ethod of managing patients whose appointm ent extends beyond 30 days. These individuals should be monitored by on-site providers at specified intervals until their specialty appointment occurs.
A no show report should be m aintained which lists all appointm ents which occurred on every day and which did not. The reas on for not going to a specialty a ppointment should be specified and provided to the QI Committee.
13.c.
The log of specialty and other off-site appointments exists. Entries into this log should be started for every patient with an order for a specialty vi sit. This log should contain the date of the provider order for specialty care and this order should continue for rescheduled appointments.
13.d.
An Obstetrician is now accepting Jail patients. However, record s from those appointments are not available to provider staff at the Jail so they do not know the condition of the patient including lab values and item s that should be monitored. There is no standard policy or procedure for the care of pregnant wom en. I recommend that this policy contain tim eline requirements of visits for prenatal care as well as the tim eliness of the first visit upon incarceration. All pr egnant females should receive a provid er visit the first opportunity after incarceration unless a complication exists which should be specified in policy. The timeliness of visits must adhere to ACOG standards.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The program should increase the capacity for specialty visits. 2. Specialty appointments which are cancelled beca use of lack of transport officers should
be tracked and reviewed by the Quality Im provement Program. The time f rom provider order to the appointm ent should be tracked and reviewed for appropriateness by the Medical Director. 3. Sufficient officer staffing s hould be assigned to transpor t patients for scheduled appointments. 4. Persons who fail to go to a sc heduled appointment should be tracked and the reason for the missed appointment should be provided. Th is information should be provided to the Sheriff on a regular basis.

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5. Pregnant females should be eval uated by an obstetrician within a week of incarceration. Prenatal lab tests can be perform ed routinely upon incarceration so that they will be available to the obstetrician and primary care providers at the facility.
6. Information from the obstetrician should be ex changed with the medical staff at the jail and scanned into the medical record.
7. Someone on site should be cap able of performing a routine pregnancy visit for pregnant females so that care can be managed along with the obstetrician.
14. Staffing, Training and Supervision.
a. LCJ shall ensure that its health ca re structure is organized with clear lines of authority for its oper ations to e nsure adequate superv ision of th e system's health care providers.
b. LCJ shall mainta in sufficient s taffing levels of Qualified Medica l Staff and Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs
c. LCJ shall ensure that all Qualified Medical Staff and Qualif ied Mental Health Staff are adequately trained to meet the serious medical and mental health needs of in mates. All such staff sh all receive documented orientation and inservice training on relevant topics, including identification of inmates in need of immediate or chronic care, suicide prevention, and identification and care of inmates with mental illness. LCJ shall ensure that all other medical and mental health staff receive adequate training to properly imp lement the provisions of this Agreement.
d. LCJ shall ensure that Qualified Me dical Staff receive adequate physician oversight and supervision.
e. LCJ shall ensure that a ll persons providing medical or mental health treatment meet applicable state licensure and/or cer tification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health staff have current, valid, and unrestricted professional licenses.
f. LCJ shall ensure that correctiona l officers are adequately trained in identification, timely referral, and prope r supervision of inmates with serious medical needs. LCJ shall ensure that corre ctional officers are tr ained to understand and identify the signs and sy mptoms of drug and alcohol withdrawal and to recognize and respond to other medical urgencies.
g. LCJ shall ensure that co rrectional officers receive in itial and periodic training on basic mental health information (e .g., recognizing mental illness, specific problematic behaviors, additiona l areas of concern); recognition of s igns and symptoms evidencing a response to trauma; appropriately responding to mental

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illness; proper supervision of inmates suff ering from me ntal illness; and the appropriate use of force for inmates who s uffer from mental illn ess. Such training shall be con ducted by a Qu alified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
14.a.
The Sheriff has es tablished a contract with Correctional Health Indiana (CHI). This is a m ajor improvement. There are clear lines of authority internally within the organization which appear adequate. Supervision is ev ident by staf f interviews. However, there will need to be some documented review of provider and nurse performance by respective supervisors.
14.b.
A staffing plan was reviewed. It appears adequate with a couple of exceptions. There appears to be insufficient dental hours. As wel l, the dentist brings his own assistant which is OK but this arrangement should be form alized in his agreem ent. Addi tionally, the withdrawal procedures have not yet been started and there are days when there is no nurse to evaluate sick call requests. Either the system needs to get more efficient or 1-2 more nurses may be needed to address these deficiencies.
14.c.
Documentation of training is in place for medical record training received and all personnel files also include CPR training. However, other training on established procedures and policies is not maintained. This should be done.
14.d.
This program is just g etting started. The supervisi ng physician is available fu ll time at the site. With time, there should be docum ented provider performance evaluations that evaluate the clinical performance of clinicians in a meaningful way against established standards.
14.e.
I reviewed personnel files. All provider, nursing and medical assistant staff have evidence of a license. Physicians should have evidence of a credential file which includes th eir training verification, Board status if applicable, and any sanctions by licensing boards.

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14.f.
87 of 158 officers received training. I will need to verify the content of the training.
14.g.
Refer to Dr. Metzner’s report.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A proper orientation program should be put into place for all em ployees. This should include orientation to policies and procedures , security rules, and training necessary for functional competency (electronic record tr aining, OSHA training, etc.). A record of training on policies and procedures should be in place.
2. Once adequate movement officers are in place, CHI should monitor the ability to perform required sick call request evaluations and performance under the withdrawal protocol and assess whether staffing is adequate. Also, care of the infirm on the 4 th floor needs to be evaluated relative to staffing. This can’t be done until policies and procedures are finished.
3. Provider credentialing must be put into place. 4. Officer training must be tracked including name of officer, dates training occurred, and
type of training given.
15. Dental Care.
a. LCJ shall ensure that inmate s receive adequate dental care, and follow up. Such care should be p rovided in a time ly manner. Dental care shall not be limited to extractions.
b. LCJ shall ensure that adequate den tist staffing and hours shall be provided to avoid unreasonable delays in dental care.
OVERALL COMPLIANCE RATING: Non Compliance
ASSESSMENT:
15.a-b
The dentist only comes on Fridays for about 4 hours. Nurses collecting health care slips indicate that there are about 20-25 dental slips a week. The dentist is av ailable once a week at about 9 AM to 1 PM but trans port officers are only availab le between 7:30 AM until 10:30. So, i n effect, the dentist has only about an hour and a half of dental tim e a week to see patients. He sees about 6-9 patients a sessi on which is les s than the n umber of slips placed. The dental backlog is 6 weeks or longer but it appears that patients with problems leave before the dentist sees them.

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As described earlier, the dental unit is unacceptable for contemporary dental care and needs to be rehabilitated.
RECOMMENDATIONS:
1. Dental requests must be tracked in a manner similar to health service requests. 2. Patients with dental pain should not exceed a week in waiting. 3. Dental complaints with pain or inf ection must be evaluated by m edical staff pending an
appointment with the dentist. 4. Transportation officer issues must be corrected. 5. The dental unit must be rehabilitated to contemporary standards.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and re lated medical data, for every in mate who dies while in the custody of LCJ or under medical supervision directly from the custody of LCJ.
b. LCJ shall conduct a mortality review fo r each inmate death while in custody and a morbidity review for all serious su icide attempts or other inc idents in which an inmate was at high risk for death. Mortality a nd morbidity reviews shall involve physicians, nurses, and other relevant LCJ personnel a nd shall seek to dete rmine whether there was a patter n of symptoms that might have resulted in earlier diag nosis and intervention. Mortality and morbidity reviews shall occur within 30 d ays of the incident or death, and shall be revisited when the final a utopsy results are av ailable. At a minimu m, the mortality and morbidity reviews shall include:
(1) critical review and analysis of the circu mstances surrounding the incident;
(2) critical review of the procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental hea lth services/reports involving the
victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plan t,
medical or mental health services, and operational procedures.
c. LCJ shall address any problems identif ied during mortality reviews through timely training, policy revision, and any other appropriate measures.
OVERALL COMPLIANCE RATING: Non Compliance

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ASSESSMENT:

16.a-c.

The policies and procedures were not provided to m e during the audit; instea d they were sent to me by email after the audit. However, the Mortality Review Policy 16.01.11, revis ed 9/15/11, signed by an unknown party on 9/15/11, and sent to m e after the audit, is different from the policy attached to and apparently used in th e mortality review cond ucted on 11/4/11. This indicates that internally, staff are not using an agreed upon policy and procedure. Additionally, I have several problems with the policy signed on 9/15/11. These are:

•

Internal audits of a clinical policy should not be performed by the Sheriff.

•

When there is a conf lict with the Medical Director completing the mortality

review, the review should be com pleted by a different physician, not the Legal

Department.

•

The physician ultimately responsible for the mortality review should be specified.

•

The mortality review should include revi ew of the com plete medical record and

incident reports involving the detainee.

•

The Administrative Review involves an assessment of e mergency response

actions and can be perform ed by the Sheriff or other custody staff. Review of an

emergency response should be perform ed by a clinical person under supervision

of the Medical Director not by the Sheriff or other custody staff.

•

The initial summary or relevant circumstances of death should be by the Medical

Director not the Compliance Inspector. This do es not mean that the Compliance

Inspector cannot give an adm inistrative report of the de ath to custody staff. But

relative to mortality review, the Medical Director should give the initial report.

•

The policy does not require presenta tion and discussion of the separate

components of the m ortality review. In stead, my reading is that in dividuals

(Compliance Inspector, Legal Departm ent, Medical Director and psychologist or

mental health professional) com plete components of the report and subm it to the

Medical Director who e ither submits a repo rt or notifies health care staff of the

findings. Findings should be discussed as part of CQI.

In addition to the se problems with the po licy and procedure, ther e were significant problems with the mortality review which was sent to me. Besides the lack of using the signed procedure for the r eview, there we re multiple clinical problems with care of the inm ate which were not identified in the review. The clinical problems were serious. It was not also not clear who performed the review and because of the clinical care problems the person conducting the review should have been identified.

RECOMMENDATIONS FOR NEXT 6 MONTHS:

1. A mortality review committee should be estab lished as part of the Quality Im provement Committee.

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2. Mortality Review should be conducted by the Medical Director. In the event that there is a conflict with the M edical Director reviewing the case, an independent objective physician can perform the review.
3. Custody, mental health and medical should participate in these reviews. 4. The review should result in a docum ent that gives recommendations for im proving
aspects of care that were deficient as identified in the mortality review.

B. MENTAL HEALTH CARE: Settlement Agreement Part III Section B

1. LCJ shall provide adequate services to addre ss the serious mental health needs of all

inmates, consistent with generally accepte d correctional standards o f care, including

sufficient staffing to meet th e demands for timely access to an appropriate mental health

professional, to ensure qualified mental he alth staff perform intake mental health

screenings and evaluations, and to pe

rform comprehensive assessments and

comprehensive multidisciplinary treatment planning. See Section III. A.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

April 2012 Assessment:

As of July 31, 2011 all but one of the QMHP pos itions were filled (and were county employees except for the Clinical Director) as follows:

1 – QMHP Clinical Director, Ph.D. 1 - QMHP Clinical Supervisor, LCSW 4 - QMHPs, LMHC, LCSW 1 – QMHP-C (Candidate), MSW 9 – QMHS, Crisis Stabilization/Suicide Counselors, B.S. or higher

As of April 2012, the QMHP FTE allocated positions were allocated and filled as follows:

1.0 FTE 1.0 FTE 2.0 FTE 3.0 FTE 12.5 FTE

QMHP Clinical Director, Ph.D. QMHP Clinical Supervisor, LCSW QMHPs QMHP-C (Candidate) QMHS, Crisis Stabilization/Suicide Counselors, B.S. or higher

The psychiatrists’ allocation, which is not adequate for the needs of the inmate population at the LCJ, will be further discussed in a later SA provision of this report (see section B.3. e.).

The mental health clin ical director, Dr. Har man, stated that the cu rrent mental health s taff allocations were not ad equate to perform the basic requ irements as mandated by the Settlement Agreement. The basis for his assessm ent was a current list of 131 inm ates who reportedly had not yet received a m ental health evaluation. It apparently wa s not uncommon for m any of such inmates to have been incarcerated in incarcerated in the jail for 2-3 weeks.

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Other basic statistics such as the percen tage of inm ates booked who had pos itive mental healthcare screening from the initial healthcare screening was not known reportedly due to issues with the electronic medical record, CorrecTek (CT).
Recommendations for next 6 months: Resolve issues relevant to the management information system in order to be a ble to g ather basic statistics needed for both managem ent and quality improvement purposes. Many of these MIS issues a ppear to be related to staff learning m ore about the capabilities of the CorrecTek system in contrast to CT deficiencies.
2. Timely and Appropriate Evaluation of Inmates.
a. LCJ shall develop an d implement polic ies and procedures to p rovide adequate screening to pr operly identify and assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment: Policies and procedures relevant to restraint/seclusion, special needs and services, inm ate care and treatm ent, suicide prevention program , governance and administration and inmate care and treatment were reviewed with relevant staff and consultants.
Other policies and procedures, as previously summarized in the September 2011 report, still need to be developed and implemented, which include the following topic areas:
1. Mission and goal 2. Administrative structure 3. Staffing (i.e., job descriptions, credentials, and privileging) 4. Involuntary treatment including the use of forced m edications, and involuntary
hospitalization 5. Other medicolegal issues including informed consent and the right to refuse treatment 6. Limits of c onfidentiality during diagnostic and/or treatm ent sessions with pertinent
exceptions described 7. Mental health record requirements 8. Quality assurance and/or improvement plan 9. Research protocols
Recommendations for next 6 months: Complete the recommended draft policies and procedures.
b. LCJ shall ensure tha t the intake health screening proce ss referred to in Section III.A.2 includes a mental health screening, which shall b e incorporated into the inmate's me dical records. LCJ shall ensure time ly access to a Qualified Menta l Health Professional when presenting symptoms of mental illness require such care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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April 2012 Assessment:

The major improvement relevant to this Se ttlement Agreement provision since the Septem ber 2011 site visit was that as of January 2012 all intake screeni ng (including mental health/suicide risk intake form) were now completed by a Registered Nurse. In addition, it was reported that all newly booked inmates were receiving such screen ing although a QI has not been done relevant to this assertion.

As previously referenced, basic statistics such as the percentage of inmates booked who had a positive mental healthcare screenin g from the initial healthcare screening was not known reportedly due to CorrectTek (CT) problem s. In addition, there was a current list of 131 inm ates who reportedly had not yet received a mental health evaluation. It apparently was not uncommon for many of such inmates to have been in the jail for 2-3 weeks.

The following statistics were available:

Descriptive measure Total bookings Completed health screens Percent booked having health screens

January 1043 1085 104%

February 1087 1071 99%

March 1360 1339 98%

April 1259 1198 95%

Total 4749 4693 99%

Recommendations for next 6 months: Resolve issues relevant to the management information system in order to be a ble to g ather basic statistics needed for both managem ent and quality improvement purposes.
Additional instructions/documents for next tour: A QI should be performed relevant to both the initial healthcare screening and subsequent mental health evaluations resulting from positive initial healthcare screening.
c. LCJ shall ensure that the mental hea lth intake screening process in cludes inquiry regarding:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as th e death of a family member or clos e
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency,
or similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.

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OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

April 2012 Assessmen t: The m ental health intake s creening process continues to include inquiry regarding the above refe rence elements, which is unchanged from the previous site assessment. Successful implementation of this policy needs to be demonstrated via a QI process.

Recommendations for next 6 months: As above.

3. Assessment and Treatment.

a. LCJ shall ensure that any inmate wh o screens positively for mental illness

or suicidal ideation during the intake screening process, or who is otherwise

referred for mental health services, receives a comprehensive mental status

evaluation in a timely manner from a Qualified Mental Health Professional

(immediate for emergent issues, within 24 hours of referral for an expedited

comprehensive evaluation, or 72 hours

of referral for a routine

comprehensive evaluation). The comprehensive mental health evaluation

shall include a recorded diagnosis section, includ ing a standard five-Axis

diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical

Manual of the American Psychiatric Association. If Qualified Mental

Health Staff find a ser ious mental illness, they shall re fer the inma te for

appropriate treatment. LCJ shall revi ew available information regardin g

any diagnosis mad e by the inma te's community or hos pital treatment

provider, and shall account for the inmate's psychiatric history as a par t of

the assessment. LCJ sh all adequately document the comprehensive mental

status evaluation in the inmate's medical record.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

April 2012 Assessment:

Little has changed since the Septem ber 2011 site assessm ent. A February 2012 audit demonstrated significant compliance issues releva nt to tim ely mental health ass essments and frequent lack of com pleted mental health eval uation forms. The timeline ss issues were als o demonstrated by a 131 inm ate “waitlist” of in mates who had not yet been seen in a tim ely manner.

Staff reportedly was frequently not using the m ental health evaluation form due to it being very unwieldy and related to past staff vacancies that created workload issues.

Recommendations for next 6 mon ths: Rev ise the m ental health evaluation (MHE) form s in order to make them more useful user-friendly. A form designed for inform ation to be presented in a narrative style is recommended. Perform a QI relevant to the timeframe requirements of this SA provision and quality issues pertinent to the completion of the MHE.

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b. LCJ shall ensure adequate and time ly treatment for inmates whose assessments reveal serious mental illn ess, including timely and appropriate referrals for specialty care and regula rly scheduled visits with Qualif ied Mental Health Professionals.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment: Inmates with mental illness on the f ourth floor currently do not have access to group therapy treatments reportedly due to custody escort officers’ issues. Inmates in the locked down units reportedly d o not have acce ss to ou t of cell m ental health assessments, which are being done at the cell front.
Inmates on the fourth floor with m ental illness in single cells are locked in their cells 23 hours per day except for those housed in G & B section on the fourth floor. These inm ates generally have access to the dayroom areas about four hour s per day. The lack of out of c ell time for inmates in single cells was reportedly primarily due to the lack of programming space within the fourth floor.
As will be describ ed elsewhere in this repo rt, line staff indicated th at they had poor acces s to inmates related to cu stody staff issues tha t included lack of adequate nu mbers of correctional officers for escort purposes.
The underlying factors contributing to lack of compliance with this SA provision are little changed from those identified in the Septem ber 2011 site visit assessment, which included the following:
1. mental health staffing allocation and vacancy issues, 2. correctional officer allocation issues, 3. many policies and procedures were still in draft form, 4. an underdeveloped management information system (at present), 5. significant physical plant limitations, 6. lack of an active functioning QI system, 7. current mental health treatment essentially limited to medication management and limited
individual mental health counseling. Group therapy programs have not yet been initiated.
Recommendations for next 6 mon ths: Inmates with the most se rious symptoms of a m ental illness are essentially lo cked in th eir cells 23 hours a day reported ly due to prim arily physical plant issues. Such restrictions are not only non-therapeutic but are likely to m ake many of these inmates clinically worse. The current physical plant is not appropriate for many of these inmates with serious mental illnesses and alternative housing options should be explored.
Despite space being available for group treatmen t, such groups are no longer occurring due to apparent custody issues/practices. T hese issues need to be resolved in order to allow for out of cell structured activities to occur.

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c. LCJ shall ensure that treatment plan s adequately address inmates' serious mental health needs an d that the plan s contain interventions specifically tailored to the inmates' diagnoses.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessmen t: A stand -alone treatment plan fo rm has not yet been included in CorrecTek. Dr. Har man reported that significant problem s continue re: the quality of the treatment plans being produced by the mental health staff. The treatment plan is currently part of the mental health evalu ation form. The lack of adequate programm ing space and correctional officer escort allocations have contributed to th e staff exerting less efforts in the dev elopment of treatment plans.
The QA audit in February 2012 determ ined that treatment planning for inm ates on suicide precautions was not occurring.
The above assessments were consistent with my review of a sample of healthcare records.
Recommendations for next 6 months: Training, supervision, and a QI relevant to treatm ent planning needs to occur.
d. LCJ shall provide for an inmate's reasonable privacy in mental health care, and maintain confidentiality of inmates' mental health status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
April 2012 Assessment:
LCJ staff reported that little, if any, progress has b een made in this area. Intake screening is not occurring inside the sate llite medical office in booking. Rather it occurs in the corridor outside the medical office, but away from the high traffic bench area.
In addition, a QA audit in Februa ry 2012 determined that m ental health staff continues to utilize the bench area to assess inmates upon referral.
Construction on a new intake screening area is scheduled to begin in June 2012.
On the 4th floor, although the psychiatrist sees most patients in his office, the QA audit in February 2012 determined that almost all inmates on suicide precau tions are still assessed cellside, including com pletion of SR As. Visiting booths (available should the clinician feel a security issues exists) are not being utilized.
Cell front interviews routinely are done for suic ide risk assessm ents and initial segregation mental health assessments related to both physical plan issues and correc tional officer allocation shortages.

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Recommendations for next 6 months: Privac y/confidentiality in the mental health setting is similar to sterility in the surgical setting. Resolve the privacy issue.
e. LCJ shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs an d ensure th at psychiatrists see suc h inmates in a timely manner.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
The Lake County Council approved 16-hours of psyc hiatric coverage in October 2011. Marcus Wigutow, M.D. was hi red October 8, 2011 for 16 hours per week. He is at the jail four days a week for 4 hours each day. He averages seeing 12 patients per day.
161 inmates were currently being prescribed psyc hotropic medications. Audits have not been performed re: timelines of appointments with the psychiatrists.
As reported in m y September 2011 report, based on national guidelines for psychiatric services in jails and prisons and on m y experience in such settings, it is clear that 16 hours per week of psychiatric coverage a t the LCJ will be inad equate coverage. Adequate cover age is like ly to require at least 1.5 FTE psychiat rists (which could be partially filled by a psychiatric nurse practioner).
Recommendations for next 6 months: Increase the psychiatri c allocation to 1.0-1.5 FTE psychiatrists.
f. LCJ shall ensure timely and appr opriate therapy, counseling, and other mental health programs for all in mates with serious mental illness. This includes adequate space for trea tment, adequate number of Qualified Mental Health Staff to provide trea tment, and an adequate array of structured therapeutic programming.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
Significant improvement has occurred relevant to improved access for inpatient psychiatric care (see B. 3. J.).
Except for the im proved access to psychiatric hos pitalization, little progr ess has been m ade relevant to this provision of the SA. Treatment for mental health caseload inmates on the fourth floor consists of m edication management and i ndividual counseling in an office s etting with some exceptions related to concerns re: pot ential violence. Structured out-of -cell group therapeutic activities ar e currently not being offered relate d to reported custody escort issues.

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Segregation inmates generally are not receiving c ounseling in a setting that allows for adequate sound privacy related to both physical plant issues and correctional officer staffing allocation issues.
Treatment provided to mental health caseload inmates is often negatively impacted by the lack of adequate correctional officer allocations and custody practices.
Recommendations for next 6 months: As stated in B.3.b., inm ates with the most serious symptoms of a m ental illness are essentially locked in their cells 23 hours a day reportedly related to primarily physical plant issues. Such restrictions are not only non-therapeutic but are likely to make m any of these in mates clinically worse. The current physical plant is not appropriate for m any of these inm ates with se rious mental illnesses and alternative housing options should be explored.
g. LCJ shall ensure men tally ill in mates in segregation receive timely and appropriate treatment, including comp letion and documentation of regular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serio us mental illness who are placed in segregation shall be immediately and regularly evalu ated by a Qualified Mental Health Professional to determine the inmate's mental health status, which shall inc lude an assessment of the p otential effect of segregation on the inmate 's mental health. During these regular evaluations, LCJ shall eva luate whether continued segregation is appropriate for that in mate, considering the assessment of the Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
Mental health “rounds” are now being conducted on a weekly basis in the segregation units by the same clinician, who is a QMHP-C. Howeve r, the rounds did not involve the QMHP-C walking cell to cell. A process is not yet in place relevant to the mental health assessment of the potential effects of segregation on inmates newly admitted to the segregation unit. A process is not in place relevant to assessing whether an inma te’s disciplinary sanction might in any way be mitigated by their mental illness.
Mental health staff is no longer participating in the disciplinary hearing process as a finder of fact.
Recommendations for next 6 months: The m ental health rounds process should involve the QMHP walking the segregation tiers cell by cell in order to “ch eck-in” with e ach inmate. A mental health screening process should be implemented relevant to inmates newly transferred to segregation housing units, which should be performed in a confidential manner in order to assess

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relevant mental health issues. A process should eventually be put in pl ace relevant to assessing whether the inmate's disciplinary sanction might be mitigated by their mental illness.
h. LCJ shall maintain an updated l og of inmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive med ication. The log shall include each inmate's name, diagnosis or complaint, and next scheduled appointmen t. Each clinician shall have ready access to a curr ent log lis ting any presc ribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and a ccurate information regarding any medication changes ordered in at least the past year.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
As reported during Septem ber 2011, there continue d to be significant managem ent information system (MIS) issues re levant to tracking th e mental health caselo ad at LCJ, which m akes it difficult to ensure that such inmates are seen in a timely manner. However, during a CorrecTek site visit in February 2012, a new version of the system was installed to track this area. It was my understanding that reports will be generated c onsistent with the requirem ents of this SA provision.
Recommendations for next 6 months : Remedy the above m anagement information system problems.
i. LCJ shall ensure that a Qualified Me ntal Health Professional conducts an in-person evaluation of an inmate prio r to a medically-or dered seclusion or restraint, or as soon th ereafter as possible. Patients placed in med icallyordered seclusion or restraints shall be evaluated on an on-going basis for physical and mental deterioration. Seclusion or restra int orders sh ould include sufficient criteria for release.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment: The restraint/seclusion policy and procedure rem ains in draft for m. Suggested revisions were discussed with pertinent staff. No inm ates have been restrained or secluded for mental health purposes since the September 2011 site assessment.
Recommendations for next 6 months: Finalize the restraint/seclusion policy and procedure.
j. LCJ shall ensure an adequate array of crisis services to appropriately manage the psychiatr ic emergencies that occur among inmates. Crisis services shall not be limited to ad ministrative segregation or observ ation status. Inmates shall have ac cess to ap propriate licensed in- patient psychiatric care, when clinically appropriate.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment: Arrangements have been made with Logansport State Hospital and the pertinent mental hea lth center to provide acc ess to inm ates at the L CJ who are within the appropriate catchment area to be hospitalized at the Logansport State Hospita l when clinic ally appropriate and judicially approve d. Nine such inm ates have been transferred to this hospital since the last site assessment.
Attempts to make similar arrangement with the Edgewater Community Mental Health Center for inmates at the LCJ within their catchm ent area have been unsuccessful. There were 4 inm ates at the LCJ in this catchment area in need of inpatient psychiatric hospitalization.
Crisis services are were reported to include medications, individual tr eatment and observation status.
Policies and procedures regarding psychiatric e mergencies still need to be developed with particular reference to use of psychotropic m edications on an involuntary basis, crisis tea m treatment and access to inpatient psychiatric hospitalization.
Recommendations for next 6 mon ths: Continue to remedy the above described problem with lack of access to an inpatient psychiatric hospitalization or inmates in the Edgewater Community Mental Health Center catchment area.
4. Psychotherapeutic Medication Administration
a. LCJ shall ensure th at psychotherapeutic medication administration is provided when appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
Policies and procedures relevant to this issue need to be developed.
Staffing allocations for psychiatrists’ time are not adequate as previously discussed.
The Medical director and the PT committee have developed and implemented a new formulary in collaboration with the jail psychiatrist.
QI studies relevant to m edication management issues were currently lacking. Based on interviews with staff and review of healthcare records, there were clearly problems with untimely medication appointments, untimely renewal of medications and untimely notice to inmates in the context of relevant formulary changes.

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Recommendations for next 6 months: QI studies need to be performed re: m edication management issues.
b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physicia n on a regular, timely basis for a ppropriateness or adjustment. LCJ shall ensure that changes to inmates' psychotropic medications are clinically justified and documented.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
Review of selected healthcare records and in formation obtained from staff indicated that psychotropic medication orders are often not re viewed by a psychiatrist or physician on a regular, timely basis for appropriateness or adjustment. It was not uncommon to find inadequate physician documentation re: the rationale for inmates' psychotropic medications.
The previously recommended policies and proce dures relevant to m edication administration should include a policy addressing m edication noncompliance, required laboratory testing and continuity of medication issues.
As referenced in other sections of this report, review of inmates’ psyc hotropic medications by a psychiatrist or physician on a regular, tim ely basis for appropriateness or adjustm ent was problematic.
Recommendations for next 6 months: The above difficulties are m ost likely due to the inadequate psychiatrists’ staffing allocations and MIS issues. Increase the psychiatrists’ staffing allocation and remedy the MIS issues.
c. LCJ shall ensure timely implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated with psychotropic medications are seen regularly by a physician to monitor responses and potential reactions to th ose medications, including movement disorders, and provide treatment where appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE April 2012 Assessment:
See 4. a., b., & c. Also see report by Michael Puisis, D.O.
As previously referenced, policies and procedures need to be developed relevant to this provision of the SA. Audits have not been done re: medication administration.
Recommendations for next 6 m onths: Develop th e relevant policies and procedures and audit implementation.

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C. SUICIDE PREVENTION: Settlement Agreement Part III Section C.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and pro cedures to ensure the appropriate management of suicid al inmates, and establish a suic ide prevention program in accordance with generally accepted correctional standards of care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment: Significant problem s remain in i mplementation of the suicide prevention program policy as evidenced by the February 2012 audit by Lindsay Hayes whic h demonstrated that all provisions of the suicide prevention policy are not consistently followed. My findings were consistent with the results of that audit.
Recommendations for next 6 months: Train, supervise and m onitor staff in the relevant provisions of the SA.
b. The suicide prevention policy shall in clude, at a minimu m, the follo wing provisions:
(1) an operational description of the requirements for both pre- service and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
OVERALL COMPLIANCE RATING: SUBSTANIAL COMPLIANCE
April 2012 Assessment:
The suicide prevention policy includes all of the above provisions. Substantial com pliance remains.
Recommendations for next 6 months: Monitor implementation of this policy and procedure.
c. LCJ shall ensure suicide prevention po licies include pro cedures to ensure the safe housing and s upervision of in mates based on the acuity of their mental health needs.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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April 2012 Assessment:
The suicide prevention policy contains the necessary language.
Based upon a QA Audit in February 2012, all inm ates on suicide precauti ons are assigned to suicide-resistant cells.
In almost all instances, in mates were being observed according to the level of required observation. The audit found a few instances in which inmates on Close Observation status were not being observed up to 1 or 2 hours on an overn ight shift because of a shortage of available CST staff.
Recommendations for next 6 months: Continue to m onitor implementation of the relevant policies and procedures.
d. LCJ shall ensure security staff posts in all housing units a re equipped with readily available, safely secured, suicide cut-down tools.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
April 2012 Assessment:
See report by Manuel Romero.
As described in the September 2011 report, the following has occurred:
1) Each control booth of the Lake County Jail housi ng units contain a fi rst aid kit, A mbu bag, and rescue tool (to quickly cut through fibrous material).
2) AEDs are s trategically located th roughout the facility. A dditional AEDs have b een purchased and will be located in key areas of the facility as determined by the director of nursing.
3) The director of nursing or desi gnee ensures that all equipment utilized in the response to medical emergencies (e.g., em ergency response bag, code cart, oxygen tank, AED, etc.) is inspected and in proper working order on a regular basis.
Sustained compliance in effect.
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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April 2012 Assessment:
Non-suicide resistant stools were removed from all cells utilized for inmates that were placed on suicide precautions.
f. LCJ shall document inmate suic ide attempts at LCJ in an inmate's correctional record in the cla ssification system, in order to ensure that intake staff will be aware of past suicide attempts if an inmate with a history of suicide attempts is readmitted to LCJ.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
A process has been established via the suicide prevention policy and procedure that includes the following:
Whenever an inm ate is discharg ed from suicide precautions, the designated QMHP shall ente r the inf ormation into the "Pa st Medical History Scr een" (i.e. "Suicide Precautions, Date") of the elect ronic medical record. This inf ormation shall not be deleted when the inm ate is removed from suicide precautions or released from the Lake County Jail.
The EMT or other designated staff in th eir absence shall determine from the review of the electron ic medical record (i.e., "Past Med ical History Screen") whether the inmate was a medical, mental health the suicide risk during any prior confinement within the Lake County Jail. Such information shall be documented on the mental Health/Suicide Risk Intake Screening Form.
However, the above has not yet been implemented. It is my understanding that the latest version of CorrecTek has the capability of tracking suicide history but due to users’ errors implementation has been problematic.
Recommendations for next 6 months: Training, supervision and monitoring is required.
2. Suicide Precautions.
a. LCJ shall ensure that suicide p revention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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April 2012 Assessment:
The February 2012 audit found a few isolated instances in which inmates on Close Observation status were not being observed up to 1 or 2 hours on an overnight shift because of a shortage of available CST staff.
Recommendations for next 6 mo nths: Perform quality improvem ent audit r elevant to th is Settlement Agreement provision.
b. LCJ shall ensure that when staff in itially place an inmate o n Suicide Precautions, the inma te shall be searched and monitor ed with consta nt direct supervision until a Qualif ied Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Until such an assessme nt, inmates shall be placed in gowns recommen ded and approved for use with suicidal patients.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
The QA Audit of February 2012 found that all inm ates initially placed on suicide precautions are provided only a safety sm ock, safety blanket, and m attress. Conside ration is rar ely given for clothing after a 24-hour reassessment. Contrary to suicide prevention policy requirem ents, QMHPs are not clinically justifying removal of clothing during each assessment.
Recommendations for next 6 mon ths: Provide training, supervision and monitoring of this SA provision.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified Medical or Mental Hea lth Staff shall write orders setting forth the conditions of the watch, including bu t not limited to allowable clothing, property, and utensils. These con ditions shall be alter ed only on th e written instruction of a Qualified Mental Heal th Professional, except under emergency circumstances.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
See C.2.b above.
The QA Audit of February 2012 found that all inmates initially placed on suicide precautions are routinely denied showers, visi ts, or telephone calls. All inm ates receive only finger foods. Consideration is rarely give n for changing these conditions after a 24-hour reassessm ent. Contrary to suicide prevention policy requirements, QMHPs are not clinically justifying removal of privileges.

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Recommendations for next 6 mon ths: Provide training, supervision and monitoring of this SA provision.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Staff shall assess and interact w ith (not just observe) inmates on Suicide Precautions on a daily basis.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
The policy was approved 7/15/11. Increased intera ction utilizing MHT/CIS (QMHS) staff began 6/22/11 with daily and weekly notations in CT. QMHPs began utilizing “MH Rounds” tem plate in CT on 7/29/11. SO AP-formatted requirements were issued by MH Dir ector on 7/15/11, with expectation that new formatting will commence by 8/31/11. Auditing will then begin and be ongoing.
A review of randomly selected medical records of inmates recently placed on suicide precautions indicated a lack of compliance with the requirement of daily progress notes written by a QMHP.
The QA Audit of February 2012 found that m ost, but not all, in mates placed on suicid e precautions are ass essed by QMHP staff on a daily basis. There were concern s, however, regarding the quality of documentation in the progress notes to justify continued management on suicide precautions.
Recommendations for next 6 mon ths: Provide training, supervision and monitoring of this SA provision with particular reference to the quality of the progress note documentation.
e. LCJ shall ensure that inma tes will only be removed from Suicide Precautions after approval by a Qua lified Mental Health Professional, in consultation with a psychiatrist, af ter a s uicide risk assessment indicates it is saf e to d o so. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
The February 2012 Q A audit indi cated a lack of consistent documentation relevant to consultation with the psychiatrist and inconsis tent implementation of the follow-up assessm ents following discontinuation of suicide precautions. There were also con cerns regarding treatment planning not being developed for each inm ate in compliance with criteria for treatment planning in the suicide prevention policy.

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Recommendations for next 6 mon ths: Provide training, supervision and monitoring of this SA provision.
3. Suicide Risk Assessments.
a. LCJ shall ensure that any inmate s howing signs and symptoms of suicide is assessed by a Qualified Mental Health Professional usin g an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
A February 2012 audit result that found that m ost, but not all, inm ates placed on suicide precautions are assessed by QMHP staff within 24 hours utilizing the S uicide Risk Assessment form. Most were assessed within an hour after referral.
Recommendations for next 6 mon ths: Provide training, supervision and monitoring of this SA provision.
b. LCJ shall ensure that the risk assessment shall include the following and findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record:
i. description of the antecedent events and precipitating factors; ii. suicidal indicators; iii. mental status examination; iv. previous psychiatric and suicide risk history; v. level of lethality; vi. current medication and diagnosis; and vii. recommendations or treatment plan.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
The QA Audit of February 2012 found concerns re garding the comprehensiveness found within the completed the Suicide Risk Assessm ent forms, i.e., inconsistent quality of documentation to justify continued management on, or discharge from, suicide precautions.
In all cases, QMHP staff was ignoring the diagnos is field on the for m. The treatment planning field was also rarely completed in compliance with criteria for treatment planning in the policy.
On February 22, 2012, the findings of the QA Audit were discussed at the weekly Mental Health Staff Meeting.

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Recommendations for next 6 months: Provide training, supervision and monitoring of this SA provision.
4. Suicide Prevention Training.
a. LCJ shall review and, to the ex tent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:
i. the suicide preventio n policy as revised consistent with th is Agreement;
ii. why facility environments may contribute to suicidal behavior; iii. potential predisposing factors to suicide; iv. high risk suicide periods; v. warning signs and symptoms of suicidal behavior; vi. observation techniques; vii. searches of inmates who are placed on Suicide Precautions; viii. case studies of recent suicides and serious suicide attempts; ix. mock demonstrations regarding th e proper response to a suicide
attempt; and x. the proper use of emer gency equipment, including suicide cut-down
tools.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
April 2012 Assessment:
As reported during Septem ber 2011, although th e Settlement Agreement does not specify a required length, the decision was made that all st aff receive eight (8) h ours of initial suicide prevention training, followed by two (2) hours of annual training. The policy im plemented, curriculum was developed, and trainings with Lindsay Hayes occurred from 9/12 – 13 and 9/1920, 2011 for any staff having regular contact with LCJ inmates.
The training curriculum was reviewed, and as expected , Mr. Hayes train ing program was excellent.
Recommendations for next 6 months: None
b. Within 12 months of the effective dat e of th is Agreement, all LCJ staff members who work with inmates sh all be trained on LCJ's suicide prevention program. Staff shall de monstrate competency in the verbal and behavioral cues that indicate pot ential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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April 2012 Assessment:
Since the S eptember 2011 suicide prevention training workshops, addition al correctional and mental health staff have been hi red, as well as a new medical services vender. All of these staff are scheduled to receive the 8-hour training by a QMHP in the near future.
The training for new hires is scheduled but not yet completed as originally planned.
Recommendations for next 6 months: Complete the training as planned.
D. FIRE SAFETY: Settlement Agreement Part III Section D.
Overall Comments: The specific areas of the SA that I, Manuel Rom ero, am responsible for monitoring are: Fire Safety; Sanitation and Environm ental Conditions; and P rotection From Harm. In genera l, I co ntinue to see im provements in all of these areas. The m ost significant issues that need to be addressed in order to achieve substantial compliance in my areas of the SA are to obtain the proper staffing le vels of correctional staff in order to be able to properly supervise the housing units, perform the necessary housekeeping and sanitation duties and to be able to provide adequate laundry services. Equally important is to have a sufficient num ber of correctional staff to assist m edical and m ental health care staff in supervis ing and escorting inmates to and from the housing units.
1. Fire Safety.
a. LCJ shall develop an d implement a comp rehensive fire safety pro gram and ensure compliance is appropriately docum ented. The initial fire safety plan shall be approved by the State F ire Marshal or the Crown Point Fire Chief o r Inspector. The fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever is sooner.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of fire safety related documents, staff interviews and personal observations, I found that LCJ has made considerable progress in the development and implementation of a comprehensive fire safety program. The written comprehensive fire safety program has been developed and implemented that includes: a fire safety policy and procedure; a location guide; fire safety forms; a training schedule; a training component; a written test; a practical test; and information regarding fire extinguisher maintenance. The fire safety plan also includes an inspection process and record keeping requirements. A new full-time Fire Safety Officer has been appointed for LCJ and has substantial training and experience in fire safety matters. The initial fire safety plan was reviewed and approved by the Crown Point Fire Inspector on March 29, 2012.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County Jail staff should include the Cr own Point Fire Department crew in some of their evacuation drills as recommended by the Fire Inspector in his March 29, 2012 letter to Lake County.
2. Lake County Jail staff need to ensure that th e fire sprinkler system is tested annually and maintain records of those inspections.
b. LCJ shall ensure that compreh ensive fire drills are conducted every three months on each shift. LCJ shall documen t these drills, including start and stop times and the number and location of inmates who were moved as part of th e drills.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of documents and interviews with staff and inmates, I found that the facility has developed a comprehensive fire drill program for the jail. LCJ staff continue to make improvements to the fire drill program. In April 2012 a full-time Fire Safety Officer was appointed. The Fire Safety Officer is charged with the responsibility for ensuring that the fire drill schedule is fully implemented. However, in order to achieve substantial compliance with this paragraph of the SA, Lake County staff will need to ensure that comprehensive fire drills are conducted every three months on each shift as well as documenting the start and stop times and the number and locations of inmates who were moved as part of the drills.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County staff need to ensure that they stay on schedule with re spect to their fire drill program.
2. During the next com pliance visit I will be reviewing the f ire drill sch edule and th e results of the documented fire drills.
c. LCJ shall ensure that LCJ has adequat e fire and life safety equ ipment, including installation and mainte nance of fire alarms and smoke detectors in all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
All of the housing areas and other areas of the facility are equipped with fire and smoke alarm systems. Maintenance and storage areas are equipped with fire sprinklers as well as food service areas. Facility staff continue to ensure that AED’s and SCBA’s are present in strategic areas of the jail. There were fire extinguishers available in all areas of the jail. The Maintenance Shop

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was better organized, but efforts should continue to be made to further reduce the amount of materials, equipment and other items that are stored within.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to adequately m aintain their fire and life safety equipment as required by this paragraph of the SA.
2. LCJ staff s hould continue to reduce the am ount of m aterials, equipment and ot her items that are stored in the Jail Maintenance Shop.
d. LCJ shall ensure that all fire and life saf ety equipment is properly maintained and routinely inspected.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of documents and staff interviews, I found that LCJ staff have continued to conduct inspections of all fire and life safety equipment as well as ensuring it is properly maintained. The LCJ Fire Safety Officer has now been assigned on a full-time basis to oversee the fire safety program. The duties and responsibilities of the Fire Safety Officer, including the provisions of this paragraph of the SA were approved by the Sheriff on May 2, 2012.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to conduct inspecti ons of all fire and life safety equipment and ensure it continues to be properly maintained.
e. LCJ shall ensure that emergency keys are appropriately marked an d identifiable by touch a nd consistently stored in a quick ly accessible location, and that staff are adequately trained in use of the emergency keys.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Facility staff continue to work diligently in developing and implementing a system for emergency key management. The emergency keys have been inventoried. Emergency keys have been placed in all facility control rooms and the radio room. The number of emergency keys assigned to each key ring is manageable. An emergency set of keys has been placed in the Sheriff’s Communication Center which is located outside of the Jail. A system of identifying emergency keys by touch has not yet been developed, but LCJ staff are reviewing various options for complying with this requirement. During my previous tour, I observed that the Central Control Center door could not be closed manually due to the positioning of the emergency release component. However, during this tour I found that LCJ staff had addressed the problem and the Central Control Center door can now be closed completely and can be

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locked. LCJ staff have developed and implemented a Key Control policy and a key inspection program. LCJ staff are still working on numbering all facility doors in order to match them with the proper keys. Once this process is completed and staff become familiar with the evacuation process, staff will need to be trained in the use of the emergency keys.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff need to develop a system of identifying emergency keys by touch. 2. Jail staff need to be trained in the use of emergency keys.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual overrid e in the event of an emergency in which the manual override is broken), including in th e event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. LCJ shall conduct regular security inspections and provide ongoing maintenance to security de vices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection, jail staff were knowledgeable on how the manual door unlocking system operates. During the tour I inspected and tested several locking mechanisms and doors and all were operable. LCJ staff have developed and implemented a door inspection policy. Staff are now conducting proficiency audits of staff in conjunction with fire safety drills; however, this process needs to be formalized and these audits need to be conducted on all shifts at least three times per year. Also, a full-time Fire Safety Officer is now in place and can ensure that these requirements are met and documented.
RECOMMENDATION FOR THE NEXT 6 MONTHS:
1. LCJ officials should commence form al random audits for testing st aff proficiency in performing manual unlocking of all doors with the use of m anual override system . The results of these audits should be documented.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR NEXT TOUR:
I would like to see docum ents that dem onstrate the results of the inspection s/audits that wer e conducted for the emergency unlocking system and staff response.

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g. LCJ shall imple ment competency-based testing for staff regarding fire and emergency procedures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
With the assistance of the Crown Point Fire Inspector, LCJ staff have developed a training curriculum for fire and emergency procedures. The next step in this process is to ensure that staff are trained in fire and emergency procedures. LCJ staff reported that training in this area is scheduled to commence on July 10-14, 2012.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff s hould ensure that com petency-based testing for staff regarding fire and emergency procedures is provided.
h. LCJ shall ensure that fire sa fety officers are trained in fire safety an d have knowledge in basic housekeeping, emer gency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ has assigned a full-time staff member to serve as the facility Fire Safety Officer. The duties and responsibilities for this position were articulated in writing by the Sheriff on May 2, 2012. The duties and responsibilities for this position are included as part of the fire safety plan. The person appointed for this position has an extensive background in fire safety and emergency management. She is a certified fire fighter and has attended numerous trainings in emergency management.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The LCJ Fire Safety Officer should continue to avail herself of available training on fire safety, basic housekeeping, em ergency management, the basic applicable codes , the use of fire extinguishers and other emergency equipment.
E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping and sanitation plans to ensure the proper routine clean ing of housing, shower, and medical areas. Such policies should include oversight an d supervision, including meaningfu l

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inspection processes an d documentation, as well as estab lish routine cleaning requirements for toilets, showers, and housing units.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has implemented some components of their housekeeping and sanitation plans. LCJ plans to have their overall sanitation plans and policies and procedures approved by May 15, 2012. Some of the inspection forms have been developed and are being utilized; however, the daily inspection forms for unit officers have not yet being implemented, primarily due to staff shortages. The sanitation officers are performing monthly sanitation inspections as well as being involved in special housekeeping projects such as removing graffiti from walls, cleaning out pipe chases and power washing various areas of the jail. Sanitation staff have also being involved in replacing shower curtains. Housing unit vents were much cleaner this tour than in past tours; however, this is an on-going process that needs to be made part of the cleaning and sanitation program. The medical area was much cleaner than from previous tours. However, more emphasis needs to be applied to the patient cells, particularly in the mental health areas. During the tour, I observed staff and inmates working diligently to clean and sanitize the jail, particularly the booking area. In general, because the booking area is in constant use, it needs intensified and sustained cleaning and sanitation with particular emphasis in the booking cells and shower areas. A sustained cleaning program, however, cannot be maintained without sufficient staff to provide adequate inmate supervision within the housing units and for the inmate work crews.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to implement their written housekeeping and sanitation plans for the jail as well fully implementing the inspection program.
2. LCJ staff must ensure that the housing un it inmate workers and inm ate work crews are adequately supervised by detention staff at all times.
b. LCJ shall implement a preventive maintenance plan to respond to ro utine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ staff continue to make strides in refurbishing the physical plant and making needed repairs to the plumbing system, including the shower areas, cell plumbing, refuge pits and grinders. Ceiling tiles that had been damaged by roof leaks have been replaced. The roof leaks have been repaired. There are continuous painting projects underway. The lighting system was in a good state of repair. A work order process continues to be in place and work orders can be tracked.

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LCJ staff have developed a preventative maintenance plan for the plumbing system to address immediate plumbing needs as well as long term needs.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to conduct needed re pairs to the physical plant and plum bing system.
2. LCJ staff should fully im plement their written preventative m aintenance plan including the schedules for preventative m aintenance inspections and repairs, staff assignments that are responsible for inspecti on and repairs, a desc ription of the work order system and an inventory of regularly needed spare parts and plumbing fixtures.
3. The above requirements should be addressed in a facility policy and procedure.
c. LCJ shall ensure adequate ventilation throughout LCJ to ensure th at inmates receive an adequate s upply of airflow and reasonable levels o f heating and cooling. LCJ shall review and assess comp liance with this requirement at leas t twice annually.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I observed that several inmate cells had the air vents covered with materials thus obstructing air flow. However, I did note continued improvement in this area from my previous inspections. I also observed that in many of the housing unit dayroom areas the return air flow vents were much cleaner and free of lint and debris. However, in order to maintain the ventilation system clean, it requires intense cleaning and staff supervision over the inmate crews that are performing these types of tasks. However, if detention officers are not available in the housing units to properly supervise inmates, it will be difficult, if not impossible to attain and maintain substantial compliance with the requirements of this paragraph.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should continue to intensify their efforts to ensure that cell vents are not covered by the inmates. This can be partly accomplished by conducting daily cell sanitation inspections. However, there m ust be sufficient numbers of detention officers available in the housing units in order to accomplish these tasks.
2. Maintenance and the environm ental vendor staff should continue to keep records of temperature readings of the housing units and other areas of the jail.
3. The return air vents in the housing unit da yrooms should be regularly cleaned and made free of debris.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
During the next tour, I will be reviewing LCJ efforts in attaining adequate staffing levels for providing supervision within the inmate housing units and over the inmate work crews.

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d. LCJ shall ensure adequate lightin g in all inmate housing and work areas and cover all light switches with exposed wires.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During this inspection I did not detect problems with the lighting system. LCJ staff have continued to work diligently on making repairs to the lighting system and replacing light bulbs and fixtures. I did not detect any exposed wiring during my inspection. Lighting in inmate cells and dayrooms was adequate. I did not detect rain water seepage into any light fixtures during this inspection.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to m aintain the lighting and electrical system in a good state of repair. For sustai nability purposes, LCJ staff should m ake the inspection of the lighting system part of their da ily housekeeping inspection program and preventative maintenance program.
e. LCJ shall ensure adequate pest co ntrol throughout the housing units, medical units, and food storage areas.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection of inmate housing units, program areas, the food service department, the medical area and general areas of the Jail, I did not detect a problem with pest control. LCJ continues to maintain pest control services that provides for regular inspections and pest control.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue with their pest control program.
f. LCJ shall ensure that all inmates have access to needed hygiene supplies.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I did not observe a problem in this area. Inmates had in their possession needed hygiene supplies, both at intake and in the housing units. LCJ staff continue to maintain a significant amount of hygiene supplies in storage areas.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to issue inmate hygiene supplies at intake to inmates and as needed. 2. Include in the revised Inm ate Handbook hygi ene issue quantities and f requency of
issue.
g. LCJ shall develop an d implement policies and procedures for cleaning, handling, storing, and disposing of biohaz ardous materials. LCJ shall ensure that any inmate or sta ff utilized to clean a biohazardous area are properly trained in universal p recautions, are outf itted with protective materials, and receive proper supervision when cleaning a biohazardous area.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There still does not appear to be a comprehensive coherent policy and procedure that addresses this area of operation. There are several policies that in part address this area. I observed during this inspection that spill kits continue to be made available in various areas of the facility. I also observed in the medical area (exam rooms) that biohazard containers with enclosures were available. I also observed that in the biohazard room in the medical area, the containers with biohazard materials were properly covered with lids. LCJ staff reported that a training program is currently under development for addressing the requirements of this paragraph of the SA. However, LCJ staff provide inmates with informal training in the handling and cleaning of biohazard spills and on how to access the cleaning supplies.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should have their own policy, procedur e and staff and inm ate training program for this area of operation, including the specific areas of the jail where spill kits and biohazard supplies are kept.
h. LCJ shall provide and ensure the use of cleaning chemicals tha t sufficiently destroy the pathogens and organisms in biohazard spills.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
The facility continues to use universal cleaning chemicals for cleaning biohazard spills as well as a bleach solution.

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RECOMMENDATIONS FOR THE NEXT VISIT:
1. LCJ supervisory staff should continue to en sure that staff and inm ates that clean biohazard spills follow the re commended instructions of the chemicals used f or the cleanup.
i. LCJ shall inspect and replace as ofte n as needed all frayed and cracked mattresses. LCJ shall d estroy any mattress that cannot be sanitiz ed sufficiently to kill any possible ba cteria. LCJ shall ensure that mattresse s are properly sanitized between uses.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I did not detect any frayed or cracked mattress. There continues to be ample supplies of inmate mattresses in storage for replenishment purposes. Inmates are assigned to clean mattresses between uses. Staff and inmates continue to use sanitation chemicals in accordance with the sanitizing chemical instructions. LCJ staff continue to provide written directives to the trustees and to all inmates as to the proper method of cleaning and sanitizing of mattresses.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ supervisors should continue to train and instruct staff and inm ates that are responsible for sanitizin g mattresses on the proper use of the sanitizin g chemicals. Supervisory staff should continue to insp ect and review the m attresses sanitization process and ensure it is done correctly.
j. LCJ shall ensure adequate numbers of staff to perform housekeeping duties.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has two full-time and one part-time sanitation officers. These officers continue to provide cleaning materials to inmates and to some extent they also supervise trustee workers. However, inmate workers within the housing units continue to receive little, if any, instruction and supervision for their cleaning duties. I found that sanitation in the housing units has improved from my last tour, but not significantly. The bigger problem continues to be the general lack of supervision of inmates in the housing units. For example, I observed one floor officer trying to provide supervision to inmates in eight pods or two housing units in the new part of the jail, identical to my previous finding. In the old part of the jail, I observed one officer trying to provide supervision of inmates in three to six living units (pods). It is unrealistic to expect that one officer can perform all the duties required of a floor officer and be able to perform them in a qualitative manner. I also observed that officers do not normally enter the actual inmate living

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areas, but rather patrol the outside of the dayrooms and the catwalks. If inmates are out of their cells, the officer does not go into the actual living area. I reviewed the Estimated Functional Bed Capacity Report 2010 authored by RJS and noted that the correctional officer force complement was inadequate. The report reflected a shortage of approximately 68 correctional officers. I noted a similar inadequacy as I toured the housing units as described above. Additionally, during my previous tour, the Sheriff’s Office presented a comprehensive Staffing Analysis that reflected a shortage of 65 detention officers in order to be able to operate the LCJ in a safe and secure manner as well as to be able to achieve substantial compliance with various provisions of the SA. Since my last tour, LCJ received approval from the Lake County Council to hire 12 additional correctional officers which is step in the right direction. There are simply an inadequate number of detention officers deployed into the housing units to properly supervise inmates and in particular, for supervising inmates that are performing housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to closely ex amine their correctional officer staffing levels and move towards provi ding direct inmate superv ision in the inm ate housing units in order to better supervise in mates and the housekeeping and sanitation program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
It is expected that LCJ officials continue to work with the Lake County Council in obtaining the proper staffing levels in the correctional officer ranks in order to be able to comply with the requirements of this paragraph of the SA.
2. Sanitary Laundry Procedures.
a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has implemented appropriate procedures for the laundry to protect inmates from risk of exposure to communicable disease. The revised policies governing this area of operation have been approved by the Sheriff. As I have reported previously, this area of operation also has staffing implications. In order for LCJ to be able to maintain the laundry operation at this level and in order to be able to implement the proposed laundry schedule, as well as to be able to adequately distribute and pick-up laundry services to inmates in an orderly fashion, the laundry operation will have to expand its hours of operation as well as ensuring that there are ample numbers of detention officers in the housing units to assist in the laundry process. Since my last tour, LCJ officials have implemented a twice weekly laundry exchange program for the female population. This is certainly a step in the right direction.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should ensure that there ar e adequate levels of detention officers available to be able to implement the revised laundry schedule.
b. LCJ shall ensure that inma tes are provided adequate clean clothing, underclothing and bedding, cons istent with generally a ccepted correctional standards (e.g., at least twice per week), and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of purchasing records and observation, LCJ officials continue to maintain a substantial amount of inmate clothing, bedding and towels in order to satisfy this requirement of the SA. However, due to inadequate detention officer staffing levels, LCJ officials have not distributed or issued these items to inmates in accordance with the revised inmate laundry schedule, with the exception of the female population as previously noted above. Based upon my observations, review of documents and staff and inmate interviews, inmates are still not being provided with adequate quantities of clean clothing, underclothing and bedding. For example, laundry exchange still only occurs once per week instead of the required two exchanges per week for the male population. Inmates are only provided with one uniform, one sheet, one towel, one blanket, one mattress and a laundry bag. It appears that blankets are now being exchanged at least once per month which is an improvement from previous tours.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is my recommendation that the inmate initial issue for bedding and hygiene consist of: one mattress; two bed sheets; two towels; and one blanket. The sheets and towels should be exchanged at least once per wee k, unless inmates are only issued one sheet and one towel, then they should be excha nged twice per week. Records of services should be maintained.
2. LCJ should ensure that there are sufficient numbers of correctional officers available in order to implem ent the revised laundry sc hedule and to distribute adequate levels of clothing and bedding items to inmates.
c. LCJ shall train staff and educate inmates regarding laundry sanitation policies.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
It appears that a private vendor has continued to provide training to laundry staff. Security staff were provided training on the provisions of the SA as it relates to laundry issues. A system has not yet been developed and implemented for educating inmates regarding laundry sanitation

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policies. Staff reported that the Inmate Handbook could be used as one avenue for educating inmates on laundry sanitation policies; however, formal revisions to the Inmate Handbook are still pending. LCJ staff also reported that they intend to post laundry and sanitation expectations for inmates in the housing unit areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the provisions of the SA in their basi c and on-going staff training program so that security and la undry staff are fully aware as to their obligations regarding the facility sanitation policies.
2. The Inmate Handbook should be revised, finalized and include the expectations of inmates regarding laundry sanitation policies.
d. LCJ shall ensure that laundry deliv ery procedures protect inmates from exposure to communicable diseases by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed practices that protects inmates from exposure to communicable diseases. The laundry carts are cleaned and sanitized between uses. Staff and inmates are following the manufactures recommended instructions for the proper use of sanitizing chemicals. Facility staff have received training on the proper use of chemicals. Material Safety Data Sheets continue to be made available in various areas of the jail. I did not detect that clean laundry was coming into contact with dirty laundry or contaminated surfaces. LCJ staff have provided written instructions to inmates on the proper use of sanitizing chemicals.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to provide instructions and oversight to staff and inmates on the proper use of sanitizing chemicals and on cross-contam ination precautions.
2. LCJ staff should continue to m aintain Material Safety Data Sheets in strategic areas of the jail where chemical are used and maintained.
e. LCJ shall require inmates to provide all clothing and linens for LCJ laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The Inmate Handbook has not been revised to include provisions on prohibiting inmates from washing and drying laundry outside the formal procedures. During this tour, I did not observe

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inmates washing undergarments, clothing and towels in the sinks, showers or toilets. At least for the female population, LCJ has started to provide laundry exchange twice per week which is an improvement from previous visits. However, the laundry exchange for the male population still only occurs once per week. LCJ staff have not fully implemented the revised laundry schedule due to the lack of staffing.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should contain a prov ision prohibiting inmates from washing and drying laundry outside the formal procedures.
2. Inmates should be issued sufficient quantitie s of clothing and towels to provide for proper hygiene and laundered as previously recommended in this report.
3. LCJ officials should implem ent the re vised laundry schedule and inmate issue provisions concomitant with an adequate facility staffing deployment plan.
3. Food Service.
a. LCJ shall ensure that food service at LCJ is operated in a safe and hygienic manner and that foods are served and ma intained at safe temperatures, and adequate meals are provided.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
From my observations and interviews with staff and inmates, I found that adequate meals continue to be provided. Meals are prepared in a safe and hygienic manner. LCJ food service staff have made improvements in the area of food temperatures. Temperature readings of meals are taken and recorded. These temperatures are satisfactory. Food carts continue to be delivered to the housing units in a more prompt manner which has immensely helped in maintaining proper food temperatures at serving time. Once the carts are delivered to the housing units I observed that the meals were promptly provided to the inmates. However, this area will need to be monitored closely due to the typical shortage of staff in the housing units.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Supervisory staff should continue to m onitor food service operations and ensure that food service staff obtain and document food temperatures.
2. Management staff and food service staff need to ensure that m eals continue to be delivered and provided prom ptly to inm ates so that problem s are not encountered with food temperatures.
b. LCJ shall ensure that all food service st aff, including in mate staff, must be trained in food service operations, safe food handling procedures, an d appropriate sanitation.

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OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection I met with food service staff and the dietician as well as conducting an inspection of the kitchen. Many improvements continue to be made in this area since my last inspection. For example, the dumpsters are cleaned on a weekly basis, bumper guards were installed throughout the kitchen, and the kitchen was repainted, among many other improvements. The dietician has continued to train staff as well as inmates on food service operations, the safe handling procedures and on appropriate sanitation. Records of these trainings are maintained. Material Safety Data Sheets continue to be made available in the kitchen.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to m aintain their tr aining records for food service staff and document all training provided, including food se rvice staff orientations. Copies of these staff training sessions should be provided to the LCJ Training Coordinator.
c. LCJ shall ensure that kitchen(s ) are staffed with a sufficient n umber of appropriately supervised and trained personnel.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
The food service department continues to be staffed with nine food service workers. The food service operation continues to be supplemented with inmate workers. The number of staff assigned to the kitchen appears to be sufficient; however, any reduction on the current staffing levels could have negative implications on the food service operation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to m aintain at the very least, the current food service staff complement.
d. LCJ shall ensure that dishes and u tensils, food preparation and storage areas, and vehicles and containers used to tr ansport food are appropriately cleaned and sanitized.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
During this tour, I found that dishes and utensils, food preparation and storage areas continue to be clean and sanitary. I also noted that the food service delivery carts and food tray storage carts continue to be appropriately cleaned and sanitized.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the daily, weekly and monthly sanitati on inspection program continues to be part of the food service system.
e. LCJ shall check and record, on a regu lar basis, the tempera tures in the refrigerators, coolers, walk-in-refrigerators, the dishwasher water, and all other kitchen equipment with temperature monitors to ensure proper mainte nance of food service equipment.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed and continue to maintain a system for checking and recording temperatures of the refrigerators, coolers, walk-in refrigerators and the dishwasher. LCJ staff are maintaining logs of these checks.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is m y recommendation that temperatu res of all ref rigerators, coolers, walk-in refrigerators and the dishwasher water cont inue to be checked and recorded. This will allow food service staff to detect a te mperature problem promptly so it can b e corrected.
F. QUALITY IMPROVEMENT PROGRAM: Settlement Agreement Part III Section F.
1. LCJ shall develop and implement written quality management policies and proced ures to regularly assess, identify, and take all reas onable measures to as sure compliance with each of the provisions of this Agreement, as applicable.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
Basic policies and procedures are in draft form re: a quality improvement program. Little change since September 2011.

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Recommendations for next 6 months: Complete and implement the needed policies an d procedures.
2. LCJ shall develop an d implement policies to address and correct d eficiencies that are uncovered during the course o f quality ma nagement activities, including monitoring corrective actions over time to ensure sustained resolution.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
F.1 policy needs to be implemented in order to implement this provision of the SA.
The February 2012 QI audit by Lindsay Hayes was a very useful QI activity. Dr. Harm an has also initiated some audits for management purposes.
Recommendations for next 6 months: Complete and implement the needed policies an d procedures.
3. LCJ shall institute a Quality I mprovement Committee and ensure th at such committee meets on a monthly basis and th at this committee includes representatives from medical, mental health, and custody staff.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
April 2012 Assessment:
A QI committee has been established, which has met on one occasion during February 2012.
Recommendations for next 6 mon ths: The QI committee should meet on a monthly basis and maintain adequate minutes.
4. Quality management programs related to me dical and mental hea lth care will utilize performance measurements to a ssess quality of care and timely access to care with quantitative and qualitative da ta analysis and trending o ver time an d specifically shall address: a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of suicide attempts, monitoring of inmates on suicide observations or precautions; d. the appropriateness of physical plan t facilities such as safe cells for management of at risk inmates, and follow-up and treatment for those who may have engaged in suicidal or self-harm activities; e. the appropriateness of treatment pla nning and treatment interventions for inmates in the mental health program;

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f. discharge planning for the ef fective management and c ontinuity of care for inmates leaving the system; and
g. the quality of medical records and other documentation.
OVERALL COMPLIANCE RATING: NON-COMPLIANCE
April 2012 Assessment: Very little progress has occurred re: these SA provisions.
Recommendations for next 6 months: Complete and implement the needed policies an d procedures as previously referenced.
G. PROTECTION FROM HARM: Settlement Agreement Part III Section G.
5. Use of Force by Staff.
a. LCJ shall develop and mainta in comprehensive and contemporary policies and procedures surrounding the use of fo rce and with particu lar emphasis regarding permissible and impermissible use of force.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff have developed and are m aintaining comprehensive and contem porary policies and procedures surrounding the use of force and em phasizes permissible and im permissible use of force. The revised Use of Force policy was signed by the Sheriff on September 14, 2011.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The finalized policy concerning the Use of Force should continue to be implemented.
b. LCJ shall address the following impermissible uses of for ce in its use of for ce policy and in the pre-service and in -service training programs for correctional officers and supervisors:
(1) use of force as an initial response to verbal insults or inmate threats;
(2) use of for ce as a resp onse to in mates’ failure to fo llow instructions where there is no immedia te threat to the safety of the institution, inmates, or staff, unless LCJ has at tempted a hierarchy of nonphysical alternatives that are documented;
(3) use of force as punishment or retaliation;
(4) striking, hitting, or punching a restrained inmate;

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(5) use of force against an inmate after the in mate has ceased to offer resistance and is under control;

(6) use of choke holds on an inmate; and

(7) use of unnecessary or excessive force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The final Use of Force Policy and Procedure c ontains the provisions of paragraph b. and subparagraphs 1-7 of the SA.

The Use of Force pre-service and in -service training program on the Us e of Force Policy and Procedure has been initiated. L CJ has provided training on the Us e of Force p olicy to six instructors. Since m y last visit, 24 correctional officers have received training on the Use of Force Policy. Training on the Us e of Force policy is now part of the pre-service and in-service staff training program. LCJ staff are working diligently on implementing the revised use of force program, but it will take some time to train and retrain all LCJ staff on this new program.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

LCJ officials need to continue to trai n correctional staff on the Use of Force

policy.

c. LCJ shall develop and implement a policy to ensure that staff adequ ately and promptly report all uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of For ce Policy and Procedure has been developed and finalized. The policy contains this provision of the SA. LCJ staff have commenced the process of providing training on the Use of Force policy to staff as noted previously above.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. LCJ officials should commence a process of monitoring this requirem ent of the SA internally.
2. LCJ staff s hould start to qualitatively tr ack, review and analyze use of force incidents for conformance with the SA.

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d. LCJ shall ensure that use of force reports will:

(1) be written in specific terms in order to capture the details of the incident;

(2) contain an accurate account of th e events leading to the use of force incident;

(3) include a description of the weapon or instrument(s) of restraint, if any, and the manner in which it was used;

(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;

(5) state the nature and extent of in juries sustained both by the inmate and staff member;

(6) contain the date and time medical attention was actually provided;

(7) describe, in factual terms, the type and amount of force used and precise actions taken in a particular incident and avoid use of “boiler plate” descriptions for describing force, such as, “inmate taken to the grou nd with the force that was necessary;” and

(8) note whether a use of force was videotaped. If the use of force is no t videotaped, the reporting correctional officer and supervisor will provide an explanation as to why it was not videotaped.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policy and Procedure contains the elements of this provision of the SA including sub-paragraphs d. 1- 8. The revised Use of Force Policy and Procedure has been approved and signed and implementation has commenced.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented.

2. I would als o recommend that a n ew use of force report f orm be developed and

implemented that includes all the elements of this provisions of the SA.

e. LCJ shall require prompt administrative r eview of use o f force repo rts. Such reviews shall include case-by-case review of individual incidents of use of force as well as more sy stemic review in order to identify patterns of incidents. LCJ

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shall incorporate such information into quality management practices and take necessary corrective action.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policy an d Procedure contains the provisions of this paragraph of the SA. LCJ staff have commenced the process of training staff on the revised Use of Force policy.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented and continue to train security staff and supervisors on it.

2. It is also my recommendation that all use of force incidents continue to be

reviewed by the Deputy Warden of Security and the Warden.

3. During my next review I will be review ing use of force reports and the review

process of use of force incidents.

f. LCJ shall ensure that Qualified Medi cal Staff reques t that inma tes sign arelease of medical records for the limited purpose of adminis trative and investigative review o f any inciden t involving an inmate injury. Q ualified Medical Staff will docu ment the re quest and the inmate’s response. LCJ will ensure that inmates receive adequ ate medical care regardless of whether they consent to release their medical records.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

This provision of the SA is addressed in the re vised Use of Force Policy and Procedure. LCJ staff and their consultants are working with Dr. Ron Shansky on ensuring that these requirements of the SA are met and are also addressed in medical policy and procedure.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. It is recom mended that the m edical policies and procedures be developed and finalized and include these prov isions of the SA and that both security and medical staff start receiving training on them.

g. LCJ shall ensure that managemen t review of use of force reports an d inmate grievances alleging excessive or inappropr iate uses of force includes a timely review of medical docu mentation of inma te injuries as rep orted by Qualified Medical Staff, includ ing documentation sur rounding the initia l medical encounter, an anatomical drawing that depicts the areas of sustained injury, and information regarding any further medical care.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the rev ised Use of Force Policies and Procedures. RJS consulting staff are wor king with th e medical staff in ensuring that the medical policies and procedures address these provisions of the SA as well.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ Staff s hould continue with the im plementation the revised Use of Force Policy and Procedure.
2. The medical policies and procedures s hould be developed and im plemented and should contain the provisions of this paragraph of the SA.
h. LCJ shall establish criteria that trigger re ferral for use of force inv estigations, including but not limited to, injur ies that are extensive or serious; injuries involving fractures or head trauma; injur ies of a suspicious nature (including black eyes, broken teeth, injuries to th e genitals, etc.); injuries that require treatment at outside hos pitals; and reports of e vents by sta ff and inma tes that are inconsistent.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. As addressed previously in this report, som e staff tr aining has already been conducted regarding this provision paragraph of the SA. However, all staf f need to be trained o n it as part of the pre-service and annual in-service staff training program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to train all correctional staff on the revised Use of Force Policy and Procedure.
2. During the course of use of force revi ews management staff should start to qualitatively assess the triggering criteria for use of force investigations and make the necessary referral to IA.
i. LCJ shall develop and implement a system to track all incidents of use of force that, at a minimum, includes the following information:
(1) a tracking number; (2) the inmate(s) name; (3) housing assignment;

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(4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA ha ve been incorporated into the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved, signed and partially implemented. The system to track all incidents of use of force has not been developed or implemented. RJS Consultants should be able to provide guidance in this c ritical area of the use of force program.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The revised Use of Force Policy and Procedure should continue to be

implemented.

2.

The system for tracking a ll incidents of use of force should be prom ptly

developed and implemented.

j. LCJ shall ensure that as part of a us e of force incident package, security supervisors shall ensure that photogr aphs are taken of any and all reported injuries sustained by inmates and staff promptly following a use of force incident. The photographs will become evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA a re contained in revised Use of Force Policy and Procedure. The revis ed Use of Force Policy and Procedure has been approved and signed and partially implemented. There has been some training provided on these provi sions to LCJ staff. Video recordings of use of force incidents are maintained by the Deputy W arden. Supervisors are required to obtain photographs of reported injuries sustained by inmates during a use of force incident.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy should continue to be implemented in order to be able to fully evaluate compliance with the SA.
2. During the next tour, I will be reviewi ng video recordings and photographs taken following use of force incidents.

k. LCJ shall establish an “early warn ing system” that will d ocument and track correctional officers who regularly employ force on inmates and any complaints related to the excessive use of force, in order to alert LCJ administration to any potential need for retraini ng, problematic policies, or supervision lapses. Appropriate LCJ leadership, supervisors, and investigative staff sh all have access to this information and monitor the occurrences.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT: An early warning system is addressed in the revised Use of Force Policies and Procedures. The revised Use of Force policy and procedure has been approved and signed and implemented. It is too early to ev aluate the o verall requirements of these provis ions of this paragraph of the SA because the overall sys tem is not yet develop ed and im plemented. Currently, there is an inform al process in place whereb y the Deputy W arden reviews and monitors use of force reports.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented.

2. Concomitant with the implem entation of the Use of Force Policy and Procedure,

LCJ staff s hould start deve loping and im plementing the early warning system

described in the revised Use of Force Policy and Procedure. RJS Consultants can

assist LCJ in this endeavor.

l. LCJ shall ensure that a supervisor is present during all planned uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

This provision is addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approve d and signed and partially im plemented. It appears that a supervisor is deployed to planned uses of force events.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and implemented.

Procedure should continue to be

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2. During the next tour I will be reviewing planned uses of force f or compliance with this provision of the SA.
m. Where there is eviden ce of staff mis conduct related to inappropriate or unnecessary force against inmates , LCJ shall initia te appropriate personnel actions and systemic remedies, as appropriate. LCJ shall disciplin e appropriately any correctional officer found to have:
(1) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or other staff member for reporting the use
of excessive force; or (4) interfered or failed to cooperate with an internal investigation regarding
use of force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy an d Procedure contains the provisions of this paragraph of the SA. The revised Use of Force Policies and Procedures have been approved, signed and partially implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the revised Use of Force Policy and Procedure continue to be implemented so that full compliance can be evaluated with respect to discipline of staff that have used inappropriate or unnecessary force against inmates.
n. LCJ shall develop and implement accountability policies and procedures for the effective and accurate maintenance, inventory and assignment of chemical and other security equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedures address incapacitating agents, electronic control devices and the us e of the restrain t chair. Th e procedure for the m aintenance, inventory and assignment for the electronic control device is addressed in the use of force policy. However, the policy does not contain those contro ls for restraint equipm ent such as handcuffs and leg irons. However, LCJ m aintains other po licies and procedures governin g all security equ ipment and have been cross-referenced with the Use of Fo rce Policy and Procedure and contain the specific provisions of this paragraph of the SA. 1 During this tour I reviewed use of force incidents. I
1 During the course of my inspection I noted that detention staff are required to purchase their own OC spray. I also noted that some officers carry OC spray that has expired. In most jurisdictions, the facility provides detention staff

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noted that in many instances where the Taser was deployed, it was generally used on mentally ill inmates or in the intake area. In my review of the use of the Taser incidents, I noted that it is not always deployed in a safe m anner. For example, the target area should not be in chest area, but some inmates were tased in that area of the body and in som e instances, while not necessarily intended, were tased to the neck or face area. I further noted that s ome inmates were tas ed multiple times with both the electronic prongs and in the drive stun mode with the Taser in conjunction with physical force and restraint operations.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. RJS staff indicated that they would be working with LCJ staff in addre ssing the proper use of the Taser and its app lication on m entally ill inm ates. During the next tour I will be reviewing use of force reports and also assess ing efforts LCJ staff have made on the proper use of the Taser.
o. Use of Force Training:
(1) LCJ shall develop an effective and comprehensive tra ining program in the appropriate use of force.
(2) LCJ shall ensure that correctional officers receive adequate training in LCJ’s use of force policies and procedures.
(3) LCJ shall ensure that correctional officers receive adequate training in use of force and defensive tactics.
(4) LCJ shall ensure that correctiona l officers receive pre-service and inservice training on reporting use of force an d completing use of force reports.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The staff training provisions for the requirem ents of this paragraph of the SA have been developed and the im plementation process has co mmenced. Six use of force instructors have been identified and have received an 80 hour tr aining course on the use of force. A 40 hour training course on the use of force for officers a nd supervisors has been developed and partially implemented. The 40 hour block of use of force training will be provided to all new correctional officers as well as a 4 hour annual refresher course on the use of force.

with all security equipment including OC spray. It is difficult for LCJ supervisors to maintain strict accountability and control of chemical agents when detention staff are required and allowed to purchase their own OC spray. As the new Use of Force policy is implemented it will be difficult for LCJ to comply with the provisions of this paragraph of the SA under the current practice of OC spray issuance.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to provide staff training to all officers and supervisors on the use of force in accordance with their training schedule.
p. LCJ shall e nsure that inmates may report allegations of the use of excessive force orally to any LCJ staff member, who shall reduce such reports to writing.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. The revised Use of Force Policies and Proce dures have been approved signed and partially implemented. LCJ officials should m onitor this provision during the course of use of forc e reviews. A lso, this reporting provision should be addressed in the Inm ate Handbook so that inmates are fully aware of reporting avenue.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. LCJ staff s hould revise the Inm ate Handbook and insert language that allows inmates to report allegations of the use of excessive force orally to any LCJ staff member.
q. LCJ shall ensure that Qualified M edical Staff question, outside the hearing of other inmates or correctional officers if appropriate, each inmate who reports for medical care with an injury, regarding the cause of the injury. If, in the course of the inmate’s medical encounter, a health care provider suspects staffon-inmate abuse, that health care provider shall immediately:
(1) take all appropriate steps to pr eserve evidence of the injury (e.g. , photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator;
(3) adequately document the matter in the inmate’s medical record; and
(4) complete an incident report.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
These provisions of this paragr aph of the SA are add ressed in the revised Use of F orce Policy and Procedure. The rev ised Use of Force Poli cy and Procedures has been approved signed and partially implemented. LCJ staff are working with the m edical staff to ensure that the m edical policies and procedures also contain the provisions of this paragraph of the SA.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. These provisions should also be addressed in the medical policies and procedures.
r. LCJ shall develop, assign, and train a team of specialized use of force investigators that will be charged with co nducting investigations of use of force incidents. These use o f force investigat ors shall receive at th e outset of their assignment, specialized training in in vestigating use of force incid ents and allegations.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the rev ised Use of Force Policies and Procedures. The revised Use o f Force Policies and Procedures have been approved, signed and partially implemented. The Sheriff has desi gnated two Lake County Police investigators to serve as the specialized use of force investigators as requ ired by this paragraph of the SA. During the tour I interviewed the Chief Investigator and noted that he has substantial experience in both crim inal and adm inistrative investigations and had served as Deputy Commander of Investigations for the Lake County Policy Department for approximately 6 1/2 years in addition to other law enforcement expe rience. The second investigat or also possesses substantial investigative experience. LCJ staff reported that they are in the process of developing an investigative guideline manual for use by the specialized use of force investigators.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. It is further recomm ended that LCJ officials develop and im plement their investigative guideline manual for the use of force investigative process.
3. I also reco mmend that the specialized use of force inv estigators receive for mal training on the revised Use of Force pol icy to f urther assist the m in their investigative duties.

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s. LCJ shall ensure that inciden t reports, use of force re ports and inmate grievances are screened for allega tions of staff misconduct and, if the incident or allegation meets established criteria, that it is referred for investigation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures address the provisions of this paragraph of the SA. The revised use of Force Po licies and Procedures have been approved, signed and partially implemented. Supervisory staff re portedly screen inmate grievances for allegations of abuse as well as incident reports and use of force reports.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented. 2. During the next tour I will be r eviewing the process f or screening inmate
grievances, incident report s and use of force reports for allegations of staff misconduct for conformance with this provision of the SA.

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FOURTH COMPLIANCE REPORT LAKE COUNTY JAIL DECEMBER 2012

A. MEDICAL CARE: Settlement Agreement Section III Part A.

1. LCJ shall provide adequate services to addr ess the serious medical an d mental health needs of all inmates.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

Leadership for the medical program at Lake County Jail has been in pl ace since January of 2012 and in general is perform ing well. The organiza tion is still challenged in attempting to measure performance against the Agreed Order due to in ability to obtain data from the electronic record. A notable change in the program is the beginnin g of charging inm ates for evaluation of health services requests. We discussed the metrics listed below. The program was able to provide data on several items but not all.

 The length of time from intake screening to provider assessment by acuity status. o This item should include acu ity status. Only 28% of intake screenings get a 14 day assessment, ostensibly because so many people are discharged before 14 days. As discussed, the 14-day assessm ent is less m eaningful than prom ptly evaluating high priority patients. For th is reason, it is important to provide the length of time it takes to evaluate those with chronic illness after intake screening. Also, approximately 7% of patients refuse d an initial assessm ent after screening. This is not a credible excuse.
 Percent of incarcerated detainees who receive intake screening. o 97% were done
 Percent of incarcerated detainees who receive tuberculosis screening. o I was told that all incoming inmates receive a Mantoux skin test, but data needs to be provided.
 Number of health care slips picked up daily. o 99% are paper triaged or FTF triaged w ithin 24 hours but only 36% have a FTF assessment within 72 hours. Few patients are getting follow up provider visits.
 Number and percent of health care slips picked up which are triaged with 24 hours. o 99% are triaged in 24 hours.
 Number and percent of symptomatic complaints on health care slips w hich have a face to-face evaluation within 72 hours. o 36% of symptom atic complaints are evalu ated face-to-face by a nurse. This is largely due to lack of movement officers.
 Average time from physician order to adm inistration of m edication for prescription medication. o The organization is having a hard time getting data for this. From chart reviews it appears that patien ts coming in f rom intake are receiving m edication within 24

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hours of order. The organization should study how to obtain this data.  A no show report indicating the number of specialty, sick call, and provider appointments
who showed up and w ere seen as well as those who don’t show and the reason for no show. This should include percentages.
o This was not provided but we discussed this report. The data must show all scheduled appointments and all no shows including the reason for no show.
Quality improvement metrics have not yet been developed. I would suggest that the group wor k with Dr. Shansky in developing these. I would include quality of primary care medical notes as one of these audits.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Develop metrics outlined above as part of a Continuous Quality Improvement Program.
2. LCJ shall d evelop and implement medica l care policies, procedures, and practices to address and guide all medical ca re and services at LCJ, in cluding, but not limited to the following:
(1) access to medical care; (2) continuity of medication; (3) infection control; , (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; (11) comprehensive health assessments; (12) mental health; (13) women's health; (14) quality management; and (15) emergent response.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
Much work has been done on policies but the w ork has not been specifi cally focused on the 15 required policies for this agreed order.
The team needs to focus on the 15 policies required in the Agreement. The policies need to be:  Simplified  Written for line staff  Focused on the items in the Agreed Order

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 Written as combined policy and proc edure (when a lengthy p rocedure subject to change is part of the procedu re, include it as an appendix rather than inco rporate it into the document)
 Addresses all areas of concern in monitoring

Writing policies needs to be followed by staff training and implementation. In addition, there are several areas including medication administration, intake and infirmary or special needs housing which should result in com bined custody/medical inter-agency policies which describe responsibilities of medical and custody staff. Coordinating these processes between custody and medical and committing them to writing will establish rules for operations which will exp edite attaining substantial compliance.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Develop key policie s relevant to this agreem ent and lis ted in Part A, item 2 of the Agreement.
2. Ensure leadership involvement in policy development. 3. Follow up policy development with training and implementation. 4. In key areas, have interagency policie s which coordinate custody and m edical
responsibility for certain processes: e.g., m edication administration, intake procedures, and special housing care or infirmary care.

3. Intake Screening and Health Assessments.

a. LCJ shall develop an d implement policies and proced ures to ens ure that adequate medical and mental health int ake screenings and health assessments are provided to all inmates within 14 days.

b. LCJ shall ensure that, upon admission to LCJ, Qualified Medica l Staff utilize an appropriate medical intake screening instrument to identify an d record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:

(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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any o f these items shall be referred for timely medical evaluation, as appropriate.

c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 days of h is or her arrival at LCJ sh all include a complete medical

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history, physical examination, men tal health history, and current mental statu s examination. The physica l examination shall be conducted by Qualified Medical Staff. Records documentin g the assessment and results shall become part of each inmate's medical record. A re -admitted inmate or an inmate transferred from anoth er facility who has received a documented full health assessment within the previ ous three months and whose receiving screenin g shows no change in the inmate 's health status need not receive a new full physical health assessment. For such inmates, Qualif ied Medical Staff sha ll review prior records and update tests and examinations as needed.

d. LCJ shall ensure that Qualified Medica l Staff attempt to elicit th e amount, frequency and time o f the last dosage of medica tion from ever y inmate reporting that he or she is currently or recently on medica tion, including psychotropic medication.

e. LCJ shall implement a medication continuity system so that incoming inmates' medication for serious medica l needs can be obtained in a time ly manner, as medically appropriate when medically necessary. Within 24 hours of an inmate's arrival at LCJ, or sooner if medica lly necessary, Qualified Medical Staff shall decide whether to continue the same or comparable medication for serious medical needs. If the inma te's reported medication is discontinued or changed, a Qualified Medical Profession al shall evaluate the inma te face-toface as soon as medically appropriate and document the reason for the change.

f. LCJ shall ensure that incoming inmates who presen t with curren t risk o f suicide or other acute mental health n eeds will be immed iately referred for a mental health evaluation by a Qualified Mental Health Professional. Staff will constantly observe suc h inmates until th ey are seen by a Qualifie d Mental Health Professional. Incoming inmate s reporting these conditions will be housed in safe conditions unless and until a Mental Hea lth Professional clears them for housing in a medical unit, segregation, or with the general population.

g. LCJ shall ensure that all inma tes at risk for, or demo nstrating signs and symptoms of drug and alcohol withdr awal are timely identified. L CJ shall provide appropriate treatment, housing, and medica l supervision for inmates suffering from drug and alcohol withdrawal.

h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.

i. LCJ shall e nsure that correctional of ficers supervising newly arrived inmates physically observe the conduct and appear ance of these inmates to determine whether they have a more immediate n eed for medical or mental health attention prior to or following the intake health screening by Qualified Medical Staff.

OVERALL COMPLIANCE RATING: Partial Compliance

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ASSESSMENT:

3.a.

The policy on reception screening is still incomplete. There is a separate policy and procedure. These should be combined. I was shown a draft policy but a finalized product is pending. The procedure includes acuity rankings but no direction is given as to where this acuity ranking is to be documented. I had trouble locating this in the electronic record. I discussed with medical leadership the acuity ranking system. The process of assigning acuity and follow up with a primary care provider should be included in the procedure; however, how the provider sees the patient isn’t clear and based on chart reviews wasn’t always happening. This should include timeframes for assessments. Also, it isn’t clear how the detoxification protocol will work in practice. There should be direct provider involvement in starting a detoxification protocol. TB screening and criteria for entering someone into detoxification should be included or should reference other policy.

Currently, CHI has provided for nurse intake screening 24/7; this is working well and staff are performing well. However, the intake screening is still not performed under conditions of privacy as screenings are done in the lobby of the intake area. I was shown a floor plan of the proposed rehabilitation of an existing inmate waiting area which will provide 3 screening booths and an examination room which will provide privacy for screening questionnaires and examination if required. Demolition has started on this area.

3 b. (1-7)

The existing medical intake form in electronic format is adequate for purposes of screening.

3 c.

The policy on health assessments needs to be re-worked. What should be addressed is how acuity rankings assigned by nurses in intake are addressed by providers. What should be included is the timeframe to accomplishing the assessment based on the acuity ranking. The extent of the evaluation by providers should be addressed based on their acuity ranking. Training of staff should be undertaken. After training, audits should focus on appropriate assignment of acuity by intake nurses, timeliness of provider assessments, and the quality of the assessments.

3 d.

Nurses are appropriately and reasonably obtaining medication history from incoming detainees.

3 e.

From a sample of records reviewed, patients coming into intake on medication received their first dose at the facility within a day. This occurs apparently via a telephone order. However, there is no documentation that a telephone order was taken and providers often do not sign these orders. Unsigned orders can be listed in a report. If such reports were used and managed, these

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unsigned orders could be substantially reduced. This must be done, because in CorrectTek, a nurse can write an order under a provider’s name. If not signed, it appears as if the provider is writing a prescription when, in effect, it is a nurse.

3 f.

Refer to Dr. Metzner’s report.

3 g.

The current procedure for alcohol withdrawal does not give sufficient guidance to the intake nurse. After performance of the CIWA, the nurse will need to know at what score should a patient be sent to a hospital and below what score can patients safely be housed at the jail? Also, the housing location needs to be specified. As well, the frequency of nurse follow-up needs to be specified.

Also, the choice of medication for alcohol withdrawal should be re-evaluated. Phenobarbital is not recommended for first line alcohol withdrawal. It should be reserved for refractory delirium tremens which would not be treated at the jail. Anti-epileptics generally also have no place in routine withdrawal treatment. Benzodiazepines remain the drug of choice for these patients.

Finally, specific directions for intoxication (specifically alcohol intoxication) are not present in current procedures. What is a nurse to do when an intoxicated individual is arrested?

3 h.

The intake screening information is electronically incorporated into the medical record and all records were accessible to me upon inspection. It is still possible for an individual to have two separate records. Merging records is done daily, yet this problem requires identification by a provider who notices two separate records; it should be automatically performed by the electronic medical record software.

3 i.

The intake process is not described in a standardized procedure. Due to the chaotic nature of this process, I could not verify the role of the correctional officer in this process. Officers from other jurisdictions can pressure health care staff to hasten the intake evaluation so that they can leave the facility. This may result in health care staff accepting inmates who should not be accepted into the jail. The responsibilities of the officers, including the roles of observation of inmates by officers prior to medical screening, should be codified in a standardized interagency procedure.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The system should perform an acuity ranking sy stem so that those with serious medical problems are tim ely seen after intake screening. Providers should prioritize those detainees with serious m edical conditions. Th is should be codified in a standardized policy and procedure

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2. A standardized system of review of the intake evaluations should be put in place. These documented reviews should be discussed with nurse staff and placed in their personnel record.
3. Privacy should be established for intake screening evaluations. 4. Standardized alcohol and opi ate withdrawal procedures should be developed and
synchronized with orders in the electronic r ecord. These procedures should be approved by the Medical Director and should be cons istent with standard ized treatment of withdrawal syndromes. Existing procedures must address how to use the CIWA scale to determine who should be sent to a hospital, how to start or continue medication, where patients in detoxification s hould be housed, and how follow up of detoxification is to occur. 5. Re-evaluate medication used in the withdrawal procedures. 6. CHI should work with the Sheriff to have an Interagency Intake policy and procedure which states the responsibilities of officers and medical staff in intake. 7. Verbal orders must be signed by providers and signature must be clear in the record. 8. Develop a procedure for alcohol intoxication. 9. Include in the detoxification procedure opiate withdrawal and how it will be handled.

4. Acute care.

a. LCJ shall provide adequate and timely ac ute care for in mates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will in clude timely medical appointments and follow-up medical treatment.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

The policy on e mergency medical response and adm ission to hospitals is not com pleted. There should be a procedure for em ergencies which require hospitalization and how a detainee would be evaluated and sent to a hospital. As well, there should be a procedure for onsite urgent care evaluations. There should be a log of onsite a nd offsite urgent or em ergent responses. The policy should indicate what hospitals the Jail has arrangements with for care.

A paper hospital log is in place. T his log is g enerally satisfactory. T here is a log of urgent responses from data derived from CorrectTek. This data is for matted into an Excel spreadsheet and lists details of the nursing note includ ing physical findings and treatm ent. Disposition is embedded in the note but is not documented as a separate field.

RECOMMENDATIONS FOR NEXT 6 MONTHS:

1. The policy and procedure on acute and emergency care must be completed. 2. Patients requiring hospitalization should have their clinical care at the facility evaluated
in order to identify any process or clinical quality issues wh ich are correctable. This can be part of the Quality Improvement program. 3. The urgent care log should include a disposition.

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5. Chronic care.

a. LCJ shall develop and implement a writte n chronic care disease ma nagement plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.

b. LCJ shall adopt and implemen t appropriate written clinical practice gu idelines for chronic and communicable diseases, su ch as HIV, hypertension, diabetes, asthma, and elevated blood lipids, cons istent with nationally accepted guidelines.

c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.

d. LCJ shall keep records of all care provided to inma tes diagnosed with chronic illnesses in the inmates' individual medical records.

e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evalua te the s tatus of their health and the effectivenes s of the medication administered for their chronic conditions.

f. LCJ shall ensure that in mates with disabilities or who need skilled nursing services or assistance with activities of daily living sh all receive medically appropriate care.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

5.a.

A chronic illness policy and procedure was available but needs work. The policy should include how inmates are enrolled into and out of the program; the frequency of visits; a m ethod of including uncommon diseases; when laboratory tes ting is to be done for the first time; how the disease roster is to be used; and reporting methods.

5.b.

Clinical practice guidelines for chronic illness a re not yet com pleted. I continue to recomm end using Dr. Shansky to assist in this process and to use, as applic able, established NCCHC guidelines.

5.c.

A chronic illness spreadsheet exis ts but is incomplete. W hen I checked the list, I found people on the list who did not have a chronic illness and some individuals were inaccurately labeled. In

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part, this problem is exacerbated because the elect ronic record does not provide a list of persons with their diseases. CorrectTek only lists one d isease per person even if the person has multiple diseases. This requires staff to spend additional time to perform this task.
Also, the list sent to me includes every person ever admitted over the past year who has a chronic disease. To be useful, the roster should include active detainees with disease. Also, the disease type is not related to the diagnosis of the patient but to a generic disease category which does not necessarily help in m anaging the patient. For ex ample, diabetics are placed in the hypertension category and asthmatics are placed in the pulm onary category. To the extent poss ible, inmates should be placed in the roster based on their diagnosis.
CorrectTek remains problematic as it does not satisfy the need of the organization in classifying patients by diagnosis and producing a roster of these patients.
In sum, the current chronic care roster is deficient for several reasons.
1. The roster is still derived m anually by a ch ronic disease nurse from CorrectTek and a variety of sources (CorrectTek, shift repor ts, nurse intake reports, booking information, direct provider reports) and it appears that m any errors exist. All of this shou ld be generated automatically but this occupies a full tim e chronic illness nurse to obtain this information. The chronic illness nurse’s time could be more productively spent. As well, CorrectTek only lists th e first diagnosis entered as the diagnosis. Thus if a patient has three chronic illnesses, only the first will be listed. This cr eates a def ective list as the remaining two diagnoses are not recognized.
2. The providers are inconsisten tly entering the problem into the EMR. Without this happening, the search of the EMR is not able to produce an accurate li st of persons with chronic illness and patients will be missed.
3. The system has not co nsidered designations for uncommon illn esses such as co llagen vascular disease, valvular heart disease, or cancer. As a result, persons with a serious but uncommon illness will not be found on the chronic illness roster and are at risk for being lost to follow up. Unusual diseases are not specifically tracked except by appointment. They should have a general medical list with the name of the disease.
4. The disease of the patient is not listed. This is important because staff who are using the list to identify high risk patients will be unable to do so. If a person with Chron’s disease is listed as “Gastrointestinal” then one cannot differentiate someone with Chron’s disease which is serious, from someone with reflux di sease which is not serio us. The curren t disease categories are HTN, DM, pulm onary, seizure, hyperlipidemia, hepatitis C, HIV, TB, scabies, MRSA, and pediculosis.
5. The acuity of the patient is unavailable.
5.d.
Though CorrectTek is difficult to use, it does keep a record of care provided, including medication administration and provider visits. Chronic illness visits are not identified as such in the electronic record but I could acceptably navigate through the chart nevertheless.

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5.e.
CHI has hired a chronic illness nurse who is tas ked with tra cking persons with chr onic illness and ensuring that necessary diagnostic testi ng, monitoring, and treatm ent is accomplished. She has developed a tracking spreadsheet but has ha d difficulty in iden tifying the en tire panel of inmates with chronic illness for the reasons specif ied in the previous paragraph. However, this nurse spends 50% of he r time doing the clerical wo rk just tracking patients. About 50% of tim e is spent on clinical m anagement. I was told a pr ovider will see a patient within 5-7 days fro m intake, but I couldn’t verify this.
Labs are performed by a vendor, CareEvolve, and lab data is now interfaced into CorrectTek.
Review of medical records of persons with ch ronic illness still dem onstrate missing diagnoses, dropped appointments, follow up errors, an d lack of continu ity. As part of the Quality Improvement program, medical leadership should review samples of at-risk ch ronic illness patients to test the performance of the system and chronic illness program.
5.f.
There is no infirmary in the jail. The 4 th floor of the old jail is considered medical housing. However there is no program of identification or management of inmates with special medical needs, including disabilities, or those requiring skilled nursing. The Jail will need to identify a location where such inmates can be housed and then establish policy and procedure for managing such a unit.
There is a p olicy on infirm ary care but it s tates that th e 4th floor is not an in firmary but in all respects it is used as an infirmary. For exam ple, the policy explains that the 4 th floor is to be used for respiratory isolation even though there are no negative pressure cells on the unit. The program has established procedures for m onitoring on this unit but they are not written. I was told that anyone needing infirm ary care goes to a hospital but based on the hospital log, this is not credible information.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Policy and procedure and clinic al guidelines for chronic i llness management and special needs management must be developed.
2. Management of chronic illn ess should begin in intake with identification, acuity ranking and appropriate referral to a provider. There must be a mechanism to enroll patients and dis-enroll patients in the chronic illness program.
3. Transportation issues involving getting patients to clinics must be resolved. 4. The providers m ust use a standardized m ethod of recording problem s in the electronic
record which permits maintaining a roster of persons with chronic illness. 5. Physicians must m anage chronic illness by seeing patients at appropriate intervals,
renewing medication, and perfor ming thorough evaluations pertinent to the chronic disease being managed.

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6. Lab and other testing (EKGs) should be performed as indicated by appropriate guidelines at indicated intervals. This information should be interfaced with the EMR.
7. A system of m anagement of patients with disabilities and serious m edical problems equivalent to infirm ary care m ust be established and codified in a pro cedure. Such a system would include: a. Admission by a physician b. Tracking of these 4th floor patients by name and diagnosis c. Acuity ranking of patients d. Defined interval evaluations by nursing and medical staff e. Rules for management of types of patients f. Rules for who can be admitted to the unit g. Discharge criteria h. Discharge only by a physician i. Complete access to physicians j. Adequate nursing coverage k. Physical space that accommodates ADA type patients l. A manual of care for nurses on the unit
6. Treatment and Management of Communicable Disease.
a. LCJ shall develop and implement adequat e testing, monitoring, and treatment programs for management of communicabl e diseases, including tu berculosis ("TB"), skin infections, and sexually transmitted infections ("STIs").
b. LCJ shall develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, in cluding TB, skin i nfections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
c. LCJ shall continue to test all inma tes for TB upon booking at LCJ and follow up on tes t results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LC J shall follow current CDC guidelines for management of inmates with TB infec tion, including pr oviding prophylactic medication when medically appropriate. If directed by a physician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.
d. LCJ shall ensure that any negative pr essure and ventilation sys tems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. LCJ shall docu ment results of such testing.

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e. LCJ shall d evelop and implement adequat e guidelines to ensure tha t inmates receive appropriate wo und care. Such guidelines will include precautions to limit the possible spread of M ethicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.
f. LCJ shall adequately maintain statis tical information regarding communicable disease screening programs and other re levant statistical data necessary to adequately identify, treat, and control infectious diseases.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
6.a.
CHI has an infection control nurse . She tracks TB skin tests and is currently working with CHI leadership in development of the program.
6.b.
The infection control policy and procedure and the infection control manual are still be ing developed. The TB screening policy and proce dure is co mplete and is accep table if m inor changes are made. The document references respiratory isolation, yet there is no ability at the jail to place anyone in respirat ory isolation as there are no nega tive pressure cells. Also, for persons who refuse testing, the cu rrent policy calls for placement in a single cell. Because non e of these cells are negative pressure vented, th e detainee should probably wear a mask until the chest film is performed. Also, persons who refuse TB skin testing are given a chest x-ray only if they are symptom atic. The policy for influe nza uses dated guidelines for who should be vaccinated. The cu rrent recommendation is th at all ind ividuals over 6 m onths should be vaccinated annually with a priority given to health care staff and individuals at risk.
6.c.
A policy and procedure has been written for TB screening. The curren t procedure is everyon e gets symptom screening at in take and a skin test in in take since September 8th.. If they have a disqualifier (BCG) they get a quantiferon. Reading is done at 72 hours. 75% of inmates are gone within 72 hours. So me patients refuse the test. Symp tomatic persons who refuse skin testing are given a chest x-ray or quantiferon. Those who get chest film s get a film within 24 hours and are isolated until the film is done. That isolation is ordered and docum ented. However, there are no isolation ce lls at the jail . These deta inees should wear a m ask until the chest film is done. The program should track the number of persons screened, the % positive skin tests, the num ber of refusals (includi ng their nam es), and the tim e to completion of screening.

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6.d.

There is no negative pressure ventilation system at the ja il. Neve rtheless, current policy references placement in respiratory isolation at the jail wh ich is not p ossible under existing conditions. The policy can state to place suspect individuals in a single cell but these individuals should wear a mask.

6.e.

A wound care and MRSA procedure was written. Th is procedure does not have facility specific directions. For exa mple, this procedures calls for intake nurses to screen inm ates for skin infections but does not say how th is is to be done. The current intake area does not perm it privacy examinations so I am not sure how th is would be done. Als o, contact isolation is recommended, but what does this actually m ean? W ill a nurse kno w where to house su ch a patient? The procedure calls for immediate treatm ent even t hough there is no 24/7 provider coverage. There is no mention of sanitizing cells after a MRSA diagnosis.

6.f.

A nurse is now assigned to infectio n control. Surveillance data is m odified from data taken from CorrectTek but getting standardized data has been difficult. Manual derivation of data is still done and this is subject to error. For TB skin test results, a m edical assistant reads the test and reports to infection control. Th e Infection Control nurse keeps that data. For MRSA, clin icians report presumptive cases to the Infection Contro l nurse v ia a m essage within th e EMR. The Infection Control nurse checks wh ether a culture was done . The nurse sees al l patients and if a culture wasn’t done, she orders it. I d id not have tim e to ver ify the data maintained by the Infection Control nurse. This data should be sent to the Quality Im provement Committee as regular reports.

No cases of influenza have been identified. Vaccination for influenza is offered at intake, but has not yet started this year.

For tuberculosis, surveillance consists of skin testing and is done. Surveillance data for TB should be reported to the QI committee on a reg ular basis. This shou ld include all refusals and discharges prior to testing.

Finally, it would help if the infection control nur se was working from a standardized procedure for collection of infectious disease data. Th is is best established by developing a surveillance dataset which was reviewed with the State and Local Department of Health.

RECOMMENDATIONS FOR NEXT 6 MONTHS:

1. Develop an infection control plan that

includes tuberculosis screening, MRSA

management and influenza m anagement. Th is plan should also include Occupational

Health and Safety required blood borne pathog en practices and isol ation procedures in

the event of an airborne contagious disease event.

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2. Review and edit the vaccination procedures fo r influenza in conside ration of existing ACIP guidelines.
3. Develop airborne isolation procedures consistent with Centers for Disease guidelines.. 4. Establish surveillance tracking of tuberculosis, skin test rates, conversion rates, employee
conversion rates, and MRSA rates. These da ta should be sent routinely to the Quality Improvement committee at least quarterly.
7. Access to Health Care.
a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.
b. LCJ shall ensure that the medical requ est ("sick call") process for inmates is adequate and provides inmates with adequate access to medical car e. The sick call process shall include:
(1) written medical and mental hea lth care slips available in Englis h, Spanish, and other languages, as needed;
(2) a confidential collection method in which the request slips are collecte d by Qualified Medical Staff seven days per week;
(3) opportunity for illitera te inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and
(4) opportunity for all inmates, irresp ective of primary language, to access medical and mental health care.
c. LCJ shall ensure that the sick call process includes lo gging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation of th e date and summary of ea ch request for care, the date the in mate was s een, the name of the p erson who saw him or her, the disposition of the medical or mental he alth visit (e.g., referral; whether inmate scheduled for acute care visi t), and, if follow-up care is necessary, the date and time of the inmate's next appointment. LCJ shall document the reason for and disposition of the medical or mental health care request in the inmate's medical record.
d. LCJ shall develop an d implement an e ffective system for screenin g medical requests within 24 hours of submission. LC J shall ensure sick call requ ests are appropriately prioritized based upon the seriousness of the medical issue.
e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
f. LCJ shall ensure that there is an adequate number of correctional officers to escort inmates to and from medic al units to ensure that inmates requiring treatment have timely access to appropriate medical care.

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g. LCJ shall ensure that Qualified Me dical Staff make d aily rounds in the isolation areas to give inmates in isol ation adequate opportunities to contact and discuss medical and mental he alth concerns with Qualif ied Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medica l Staff will ass ess inmates for new clinical findings, such as deterioration of the inmate's condition.
h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care will be provided regardless of the inmate's ability to p ay. No fee -for-service shall be required fo r certain conditions, including health screen ings, emergency care, and/or the treatment and care of condition s affecting pu blic health, e.g., Tuberculosis, MRSA, pregnancy, etc., particu larly for in digent inmates who are not covered by a health insurance plan or policy.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
7.a-b
Progress continues on this item . The procedure fo r this p rocess is in draft. I r eviewed the existing written pro cedure. Currently, elem ents of the non-em ergency access p rocedure are described in a scheduling procedure. The sick call (non-emergent access procedure) should be all inclusive. Several items still need to be addressed:
 Confidentiality of collection 7 d ays a week. The current procedure addresses confidentiality, but not pick up
 Slips with Spanish and English language ne ed to be addressed in the policy and procedure including who will review these slips.
 Method of access for cognitively impaired and illiterate needs to be addressed.  A methodology for tracking timeliness of triage and follow up.  How mental health, dental, urge nt medical, and routine cards are processed needs to be
described.  Description of where the patient would be triaged, have face-to-face evaluations and
where follow up would occur.  A methodology for prioritization of slips based on medical seriousness  A method to track patients not brought for evaluation by custody so that transportation
processes can be monitored.
The current system of access is s till deficient in that it is not avai lable to all inmates. “Medical Cards” are now availab le in Spanis h but it was not clear w ho evaluates these requests. I also could not verify any mechanism for the cognitively impaired or illiterate to access health care. I would suggest using a service by A T &T for tele phonic language interpretive services which is priced on a as-use basis. The procedure also do es not include how segregation, the illiterate and those who are mute or otherwise can’t communicate will access care.

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7.c-d
A reasonable log is maintained which has the date submitted, the date collected and triaged, the name, the complaint, the disposition, the acuity level, the people who had the 72 hour evaluation and appointment date. On review of a sam ple log, there were days when slips were not logged, so it app ears that this a ctivity is no t always oc curring on d ays when th e sick c all nurse is of f. Officers are still not available to transport inmates for face to face evaluation on a daily basis so only 36% of face to face evaluations occur on tim e. As a result of this lack of transportation, the sick call nurse does a cell side triage which does not permit a complete evaluation.
Face-to-face encounter notes are w ritten as “s ick call docum entation” or “sick call” notes. Triaging notes are only written on the sick call slip and there may be no docum entation in the record. The sick call log has a space for triaging and face-to-face evaluation. However, the faceto-face column is almost never filled in, meaning that either almost no face-to-face encounters are being done or that this event is not tracked. The face-to face encounters should be tracked on the log. Also, the name of the person com pleting the evaluation is not entered into the log. Acuity levels columns are in the tracking log but are seldom used.
7.e.
Nurses still perform most face-to-face evaluations cell side. Given that there are 3-4 clin ic exam rooms dispersed throughout the jail for the pur pose of sick call evaluation, there is probably adequate space for this process. However, b ecause there are in sufficient officers to brin g inmates to these rooms, nurses still go to tiers to see inmates.
7.f.
There are still insufficient officers to transport detainees for evaluations. The Sher iff agreed to correct this problem.
7. g.
This area was compliant based on the last visit review. I did not review this item on this visit.
7. h.
Lake County Jail has a co-pay po licy which requires a $15 paym ent for evaluation of sick call requests as well as doctor visits. T here was a 50% reduction in sick c all visits after the co-pay started. The policy does not address providing ca re under co-pay requirements and how inmates without funds will access care. The procedure for i mplementing a co-pay is not developed and standardized. It is not clear that appropriate exclusions are built into the program.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Sick call policy and procedure must be completed. 2. Sufficient staff should be available to evaluate all slips. 3. Transportation issues involving getting patient to the clinic must be resolved. 4. Nurses should triage all slips within 24 hours. 5. Emergent issues must be addressed immediately. 6. Slips that in clude symptoms must include a nurse face to face evalu ation in a clinical
setting. This should occur no later than 72 hours based on the clinical issue. 7. A system of tracking requests should be m aintained. The tracking log needs to have all
required elements and needs to be accurately maintained. 8. A way to d ocument a face to face evaluation by nursing should be established in the
medical record that associates with the medical card in question. 9. The “Inmate Medical Card” should be revised to include:
a. Mental health requests b. Dental requests c. A space to date the day the card was received by medical and the date triaged by a
nurse d. A space for a nurse to write a brief triaging note. e. Typical complaint types 10. Metrics should be instituted in the Quality Improvement program to include: a. The number of requests picked up daily b. The number of slips triaged within 24 hours c. The number of slips with symptoms that had a nurse evaluation within 72 hours. d. The number of slips referred for provider evaluation. 11. A monthly nurse quality evaluation should include supervisory review of a select number of nurse evaluations to ensure adequate quality. 12. All nurse evaluations should include vital signs. 13. Nurse protocols for evaluations should be developed. These m ust be approved by the Medical Director. 14. Co-pay procedures should be incorporated into the sick call policy.
5. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates w ho receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimu m, discharge instructions are obtain ed, appropriate Qualified Medical Staff reviews the information and documentation available from the vis it, this review and the outside provider's documentation are recorded in the in mate's medical record, and appropriate follow-up is provided.
OVERALL COMPLIANCE RATING: Partial Compliance

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ASSESSMENT:
8. a-b.
The hospital policy is in place but d oes not address where returning pati ents are seen, how new medication is started, or how the follow up physic ian visit is scheduled and when the follow up visit is scheduled.
Inmates returning from offsite visits are returning to intake and are seeing a nurse but the f ollow up physician visit is not always tak ing place. Based on a few charts reviewed, patien ts were noted to be seen at intake. However, based on these records reviewed the physician in follow up did not know why the patient was co ming to the clinic and saw the patient for a different reason than for review of the offsite visit. Nurs es are renewing m edication changes but these phone orders are not always signed by a provider.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Upon return from the hospital or off- site consultation, all patients should go to a standard central location and be evaluated by a nurse and physician. If a physician is not present, the nurse should evaluate the patient and c onsult with a physician regarding any change in therapy. This discussion should be documented in the medical record.
2. The patient should be scheduled for a follow up physician visit to discuss and evaluate disease status.
3. For quality purposes, the log s hould be evaluated monthly to assess whether follow up is occurring as indicated.
4. The inmate must be evaluated for renewal of medication or change in therapy based on the outside visit. The nurse must consult with a physician for these orders.
9. Emergency Care.
a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health n eeds receive timely and appropriate care, including prompt referrals and transpor ts for outside c are when medica lly necessary.
b. LCJ shall train all co rrectional officers to provide first responder assistance (including cardiopulmonary resuscita tion ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide a ll correctional officers with the necessary protecti ve gear, including masks and gloves, to provide first line emergency response.
OVERALL COMPLIANCE STATUS: Partial Compliance

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ASSESSMENT:
9.a.
There are two existing polic ies on urgent response within the jail. Neither com pletely describes appropriate procedures. These policies should be combined into a single policy and procedure.
A blood borne pathogen power point is done but an emergency response power point is not yet completed. The training has not yet been initia ted. The Medical Director is planning a training power point for officers on m edical emergencies but this has not ye t been completed. Health care staff were trained on emergencies at the beginning of the new m edical contract. There was no written course work for this training. Offi cer CPR training was provided to all be two officers.
9.b.
I randomly checked the control stations on the 3 rd floor of the new jail and 3 rd floor south of the old jail on the last visit. Both areas had a first aid kit including masks and gloves.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Medical Director should develop a trai ning module for custody staff to include serious medical conditions likely to be enc ountered at the jail (seizu re, wheezing, low or high blood sugar, intoxication, drug withdraw al, etc.) and blood borne pathogen issues. Officers should be trained a nd their training should be verified in a tracking log. The tracking log should be included in documents sent to the Monitor.
10. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical an d mental health needs of inmates a t LCJ.
b. LCJ shall develop and implement p olicies, procedures, and practices to ensure timely responses to orders for medications and laboratory test s. Such policies, procedures, and prac tices shall be periodically evaluated to ensure time ly implementation of clinician orders.
c. LCJ shall ensure that medical a nd mental health reco rds are centraliz ed, complete, accurate, readily accessible, and systematically organized. All clinical encounters and review s of in mates should be docume nted in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out of LCJ for medical care. LCJ shall obtain records of ca re, reports, and diagnostic test s received during

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outside appointments in a time ly fashion a nd include such reco rds in the inmate's medical record or document th e inmate's refusal to cooperate and release medical records.
e. LCJ shall mainta in unified med ical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
10.a.
There is an electronic record in place but staff find it difficult to use. More importantly, there are patient safety issues including:
 There can still be two or more authors for a single log on. This is a serious problem. For example, a nurse can enter a prescription under Dr. Forgey’s name under her log on.
 Diagnoses are still difficult to record. For patients with multiple diagnoses, only the first diagnosis will be liste d in a data search. This m akes it impossible to us e as a chronic illness roster.
 The electronic MAR must be d isconnected from the m edical record because of connectivity issues. Certain parameters of an order are not passed in the electronic record on the “disconnected MAR”. The disconnected MAR only has medication orders for the shift and day but does not include any other pe rtinent orders such as vital signs, dressing change, certain checks required based on m edication orders, etc. This is a serious defect. Nurses administering medication keep a paper copy of the MAR but this is only refreshed weekly. However, a weekly refresh m ay miss critical medication changes that result in patient safety issues. The refresh should be daily at a m inimum. As well resynchronization back to the electronic MAR from the “disconn ected MAR” is occasionally defective or doesn’t occur. This is also a problem.
 The record is not HIPPA compliant.
The interface with pharmacy has improved and is considered resolved. The lab interface has also been corrected. There is a down-tim e practice, but it is no t standardized into a p rocedure and this should be done.
10.b.
Policies and procedures on timely responses to orders for medication and laboratory tests need to be developed. These should include physician co-s ignature for verbal orders. T he laboratory interface has been corrected and lab values are now integrated into the electronic record.

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10.c.
An electronic record is in use. Medical prov iders do have access to th e record and the record is accessible to nurses as they adm inister medication. Laboratory resu lts are now electron ically interfaced with the record.
10.d.
When a patient goes out to a hospital, a MAR is sent with them along w ith “hospital transfer paperwork” which includes m edical history filled in by a nurse who m ay or may not know the reason for sending the patient to the hospital or specialist. Medications are also included.
The facility has continued problem s getting medical information back from the hospital. Much time is spent getting this inform ation. W hen software issues occur, they should be tracked as part of CQI. This tracking should be for mal so that all existing software issues are logged and managed. Also, the downtime procedure is incomplete. Staff should all be on the sam e page as to what the existing procedure is and downtim e paper form s must be in a loca tion which is understood by all staff.
10 e.
The electronic record is unified but is not completely electronic. Some elements are scanned into the record. This record is not HIPPA certified according to staff.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should consider an alternat e electronic record or defini tively correct existing patient safety issues.
2. Software training should occur when new employees start work as part of the orientation. 3. A system of tracking software issues shoul d be instituted to en sure that software
problems are solved. 4. A manual back up system should be in place in the event the software goes down.
Instructions in the event of software cr ashes should be docum ented in a “down time procedure”.
11. Medication Administration.
a. LCJ shall ensure that inmates r eceive necessary medications in a timely manner.
b. LCJ shall develop policies an d procedures to en sure the accurate administration of med ication and maintenance of medication re cords. LCJ shall provide a systematic physician review of the use of medica tion to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.

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c. LCJ shall ensure that medicine admin istration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. LCJ shall ensure that medication ad ministration is per formed by Qualified Nursing Staff who sh all administer prescription medications on a directlyobserved basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications withou t a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.
e. When LCJ has advance notice of th e discharge of inmates with serious medical or mental health needs, LCJ shall prov ide such inmates with at leas t a sevenday supply of appropriate prescription me dication, unless a different amount is deemed medically appr opriate, to s erve as a bridge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the pe riod of trans it for inmates who are being transferred to another correctional facility or other institu tion. LCJ shall prepare and send with transferring inmates a transfer summar y detailing major health problems and listing current medications and dosages, as well as medication history while at LCJ. LCJ shall ensure that infor mation about potential release or transfer of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a for mal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelin es for the prescrip tion of certain types of medications.
g. LCJ shall ensure that Qualified Medica l Staff counsels a ll patients who refuse medication.
h. LCJ shall secure the me dication room and disconti nue allowing food to be stored in the medication refrigerator.
COMPLIANCE ASSESSMENT: Partial Compliance
ASSESSMENT:
11.a.
Prior problems with the pharm acy vendor were di scovered to be problem s with the software vendor CorrectTek. Apparently, the HL-7 data configuration was incorrect causing m issing information. This problem was corrected. The medication renewal process is not codified in a standardized procedure. This should be done. Based on chart reviews, patients do appear to be getting their medication within 24 hours of prescription.

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11.b.
There is a p rocedure for medication issues. H owever, this policy/procedure is not written for this specific facility. As an exam ple, the medication renewal section states tha t 14 days bef ore expiration of a medication the chart is to be pulled and given to the provider to review. There are no paper records used at the facility. Clearly, this policy was written for a different facility. The policy and procedure m ust be vetted so as to conf orm to practices at this facility. The existing practices must be codified in the procedure.
Also, the policy does not explicitly describe the procedures th at the medication assistants follow when they pass medication. This should be corrected.
11.c.
Medication administration procedures m ust involve custody staff. There should be an interagency policy and procedure on m edication administration that specifies the responsibilities of officers as well as nursing st aff. The nursing responsibilitie s should include the 5 rights of medication administration in the procedure. Nurses are verifying the co rrect medication compared to the MAR entry prio r to medication delivery. Then the m edication is placed in an envelope. When the nurse goes to the unit, the id entification of the inmate is confirmed but the nurse then takes the pre-verified envelope of medi cation and administers to the inmate. This is a version of pre-pouring. I would say that th is is an accepted b ut not recommended procedure. It is recommended that verification of the right m edication should be m ade at the time it is administered. This can easily be done because the nurse has the m edication administration record available. W arden Stuart ag reed to work with m edical and Mr. Ray on an interagency procedure. The five rights are not clearly s een in the current procedure and this should be corrected.
11.d.
Medication administration is mostly performed by medical assistants. These individuals all have a certificate on file. I still have not yet been provided with State regulations which permit use of medication assistants as capable of administering medication. Nursing staff do take verbal orders from physicians. W hen this occurs, docum entation of that verbal order has to be in a progress note which I did not consis tently find. As well, I could not find evidence of physician co-signing of verbal orders. One suggestion is for the program to provide an exception report of verbal orders which are not signed as a way of improving this process.
11.e.
LCJ states that it provides 7 days of m edication to inmates who are discharged. T his should be described in the policy and procedure.

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11.f.
There is a p harmacy and therapeutic committee meeting with minutes. A for mulary is in place. Minutes of the meeting are missing for some months for 2012. The P & T m eeting is occurring in conjunction with the CQI m eeting. W hile this is acceptabl e, the m inutes should clearly indicate agenda and minute items distinguishing CQI and PT items.
11.g.
There is a p rocedure for medication refusal. However the procedure does not address how an inmate is allowed to refuse. W hen nurses administer medication nurses accept refusals from the officer that an inmate doesn’t want medication. The inmate should present to the medication cart and refuse to the nurse. This should be codifi ed in the interagency procedure which custody has committed to doing.
11.h.
The medication room is significantly cleaner at this vis it. This is lar gely due to fixing the CorrectTek interface issue, which has resu lted in accurate medication deliver. Becau se medication is now tim ely delivered, the am ount of stock has been sign ificantly reduced. The drug supply room is now neat. I did checked several narcotic veri fication sheets and there were some errors on them which I pointed out to LCJ l eadership. The medication carts are still in the nursing station and these carts have m edications in envelopes on the carts. The carts are left unattended at times. I was able to walk into th e room with a leadersh ip staff. No other nurses were present and it would be very easy to take medication off the cart. Securing these carts is still a problem.
RECOMMENDATION FOR NEXT 6 MONTHS:
1. The quality committee should develop a m echanism to establish the av erage time from prescription to delivery of medication to the patient.
2. Policies and procedures must be developed for medication administration and storage of medication. Staff m ust receive regular training on these po licies and procedures. In addition to the m edical medication administration policy, there should be an interagency procedure which specifies the responsibilities of custody and medical staff in medication administration. A start has been made on the policies but some additional work needs to be done. I did speak with the Warden on the interagency policy.
3. Medication administration must be standardized and facility specific. 4. The procedure for handling refu sals of medication must be standardized and developed
into policy and procedure. 5. Storage of medication carts should be in a secured area, away from civilians and inmates. 6. Medication renewal should include evaluation of the patient and should be facility
specific and codified in procedure.

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12. Medical Facilities.
a. LCJ shall ensure that sufficient clinical space is ava ilable to prov ide inmates with adequate medical care services including:
(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric
and pregnant inmates).
b. LCJ shall ensure that medical areas are adequately cleaned and m aintained, including installation of adequate lighting in medical exam rooms. LCJ shall ensure that hand washing statio ns in medical areas are fully equipped, operational and accessible.
c. LCJ shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including sy ringes and sharp medical tools) and hazardous waste.
d. LCJ shall provide for inmates' reas onable privacy in medical care, and maintain confidentiality of inmates' med ical status, subject to le gitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
12.a.
Sufficient space still does not exist to perform in take screening, physical assessments, and acute, chronic or s pecialty care. There is sufficient space for nurse sick call on the vario us tiers bu t there are insufficient officers to present inm ates to the nurses. The jail has a plan to renovate a room in the intake area to create an adequate space and I loo ked at the space and drawing. These appear sufficient. The existing clinic space on the 4 th floor is unacceptab le as is. Also, American with Disabilities Act (ADA) acco mmodations for disabled do not a ppear to be available on the 4th floor housing units.
The dental unit remains unacceptable.
Work has started on the intake area but only the demolishing piece has started. T he 4th floor clinic space renovations have not started. There are plans to renovate the dental area but this has not started. There are no plans for changing the 4 th floor medical unit. Plans wer e provided to me of the planned dent al clinic and the 4 th floor clinic; co nstruction is contemplated to sta rt within a month or two. There is no existing plan to address ADA or infirmary care issues.

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12.b.
The main clinic sanitation is still unacceptable. There were 8 people in the clinic; 3 pa tients, 3 providers, a nurse and an officer all of whom could listen to any one encounter. The crowding increases needle stick risk, is not private, and encourages incomplete evaluations.
12.c.
The biohazard containers in the clinic are not a ll in locations which would minimize needlestick injury. As it is, som eone with a sharp m ight have to cross into another area to deposit the sharp which is a s taff safety issue. All bio hazard containers should be located adjacent to the area of use so as to reduce moving across staff areas with a sharp.
12.d.
Privacy of care still does not exist in intake or in the clinic arrangement on the 4th floor.
RECOMMEDNATIONS FOR THE NEXT 6 MONTHS:
1. An evaluation room for medical and mental health intake evaluations must be established which permits for both security and privacy concerns.
2. Adequate clinical examination rooms need to be built for sick call request evaluations by nurses and for routine clinic examinations by providers.
3. Develop a plan for medica l and m ental health infirmary care hous ing that is ADA compliant.
4. Remedy the dental clinic situation.
13. Specialty Care.
a. LCJ shall ensure that inmates who se serious medical or me ntal health needs extend beyond the serv ices available at LCJ s hall receive timely r eferral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ shall ensure that inmates who have been referred for outside specialty care by the medical staff or another specialt y care provider are scheduled for timely outside care appointments and transported to their appointmen ts. Inmates awaiting outside care s hall be se en by Qualif ied Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ shall mainta in a current log of all inmates who have been referred for outside specialty care, including th e date of the referral, the date the appointment was scheduled, the date th e appointment occurred, the reason for

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any missed or delayed appointments, an d information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmate s are provided adequate pre-n atal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregn ant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
13.a-b.
There have been no recent problem s with scheduling due to paym ents. However, there are still no contracted providers for several necess ary subspecialty providers including nephrology, cardiology, or derm atology. There hasn’t been a di alysis patient incarcer ated since January. However, there is no plan to care for such a p atient if one were to be incarcerated. The jail attempts to get the patient released. Most appointments can be arranged within a week, however, if someone were to need cardiology or nephrology LCJ would encounter difficulties.
Patients scheduled for offsite specialty appointments are still routinel y cancelled because of no available movement officer. These events ar e not tracked; the appointm ent is m erely rescheduled. A no show repor t should be m aintained which lists all appointm ents which occurred on every day and which did not. The reason for not goi ng to a specia lty appointment should be specified and provided to the QI Committee.
13.c.
The log of specialty and other off-site appoi ntments exists but does not track cancelled appointments. The log entry should begin with the date of provider order not the date the scheduler starts the appointment process. This log should contai n the date of the provider order for specialty care and this order should document re-scheduled appointments.
13.d.
An Obstetrician is now accepting Jail patients. However, record s from those appointments are not available to provider staff at the Jail so they do not know the condition of the patient including lab values and item s that should be monitored. There is no standard policy or procedure for the care of pregnant wom en. I recommend that this policy contain tim eline requirements of visits for prenatal care as well as the tim eliness of the first visit upon incarceration. All pr egnant females should receive a provid er visit the first opportunity after incarceration unless a complication exists which should be specified in policy. The timeliness of visits must adhere to ACOG standards. The standardized procedure should adhere to ACOG standards. The tim eliness of appointments to the Obstetrician should be de lineated in the procedure. As well, the onsite management of the pregnant detainees should be delineated.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The program should increase the capacity for specialty visits. 2. Specialty appointments which are cancelled beca use of lack of transport officers should
be tracked and reviewed by the Quality Im provement Program. The time f rom provider order to the appointm ent should be tracked and reviewed for appropriateness by the Medical Director. The date of provider order for specialty care should be tracked on the specialty log. 3. Sufficient officer staffing s hould be assigned to transpor t patients for scheduled appointments. 4. Persons who fail to go to a sc heduled appointment should be tracked and the reason for the missed appointment should be provided. Th is information should be provided to the Sheriff on a regular basis. 5. Pregnant females should be evaluated by an ob stetrician within a w eek of incarceration. Prenatal lab tests can be perform ed routinely upon incarceration so that they will be available to the obstetrician and primary care providers at the facility. 6. Information from the obstetrician should be ex changed with the medical staff at the jail and scanned into the medical record. 7. Someone on site should be cap able of performing a routine pregnancy visit for pregnant females so that care can be m anaged along wi th the obstetrician. Clinical assessm ent items should be standardized so that onsite staff know what to evaluate.
14. Staffing, Training and Supervision.
a. LCJ shall ensure that its health ca re structure is organized with clear lines of authority for its oper ations to e nsure adequate superv ision of th e system's health care providers.
b. LCJ shall mainta in sufficient s taffing levels of Qualified Medica l Staff and Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs
c. LCJ shall ensure that all Qualified Medical Staff and Qualif ied Mental Health Staff are adequately trained to meet the serious medical and mental health needs of in mates. All such staff sh all receive documented orientation and inservice training on relevant topics, including identification of inmates in need of immediate or chronic care, suicide prevention, and identification and care of inmates with mental illness. LCJ shall ensure that all other medical and mental health staff receive adequate training to properly imp lement the provisions of this Agreement.
d. LCJ shall ensure that Qualified Me dical Staff receive adequate physician oversight and supervision.

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e. LCJ shall ensure that a ll persons providing medical or mental health treatment meet applicable state licensure and/or cer tification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health staff have current, valid, and unrestricted professional licenses.
f. LCJ shall ensure that correctiona l officers are adequately trained in identification, timely referral, and prope r supervision of inmates with serious medical needs. LCJ shall ensure that corre ctional officers are tr ained to understand and identify the signs and sy mptoms of drug and alcohol withdrawal and to recognize and respond to other medical urgencies.
g. LCJ shall ensure that co rrectional officers receive in itial and periodic training on basic mental health information (e .g., recognizing mental illness, specific problematic behaviors, additiona l areas of concern); recognition of s igns and symptoms evidencing a response to trauma; appropriately responding to mental illness; proper supervision of inmates suff ering from me ntal illness; and the appropriate use of force for inmates who s uffer from mental illn ess. Such training shall be con ducted by a Qu alified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
14.a.
CHI has been providing se rvices for about 10 months. They have a good leadership team and lines of authority are clear and understood by all. The program would benefit by structured performance reviews of providers and nurses.
14.b.
A staffing plan was reviewed. It appears adequate with a couple of exceptions. There appears to be insufficient dental hours. As wel l, the dentist brings his own assistant which is OK but this arrangement should be for malized in his agreem ent. One possibility m ay be to contract out dental services. There are d ental contractors who will also provi de a portable dental unit which may save renovation money.
Additionally, the withdrawal pr ocedures and infirmary care m anagement have not yet been started. This may require additional nursing staff. There are now 4 mid-level providers which is a very positive change. Using m edical assistants to administer medication is cost effective but it must be shown that this is acceptable in regards state regulations.

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14.c.
A spreadsheet is m aintained which lists whether training and personnel item s are up to date . This sheet includes credentials, license, blood borne pathogen trainin g, CPR training, suicide prevention training, and emergency response training. An employee orientation occurs but there is no documentation of orientation to job duties. One suggestion is to have the em ployee sign their job description as evidence of orientation to their duties.
14.d.
The process of provider evaluation is just getting started. The s upervising physician is available full time at the site. Some suggestions were given regarding provider performance evaluations.
14.e.
All licensure information for clinical staff is maintained up to date in an “em ployee credentials” notebook which was reviewed and is up to date. For physicians, national practitioner databank data is not obtained but should be done.
14.f.
Training records were provided and dem onstrated CPR and officer training. However, CHI still needs to develop a training program for officer s on how to recognize m edical emergencies. A way to track this will need to be developed as well.
14.g.
Refer to Dr. Metzner’s report.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A proper orientation program should be put into place for all em ployees. This should include orientation to policies and procedures , security rules, and training necessary for functional competency (electronic record tr aining, OSHA training, etc.). A record of training on policies and procedures should be in place.
2. Once adequate movement officers are in place, CHI should monitor the ability to perform required sick call request evaluations and performance under the withdrawal protocol and assess whether staffing is adequate. Also, care of the infirm on the 4 th floor needs to be evaluated relative to staffing. This can’t be done until policies and procedures are finished.
3. Provider credentialing must include National Practitioner Databank information. 4. Officer training must be tracked including name of officer, dates training occurred, and
type of training given.

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15. Dental Care.
a. LCJ shall ensure that inmate s receive adequate dental care, and follow up. Such care should be p rovided in a time ly manner. Dental care shall not be limited to extractions.
b. LCJ shall ensure that adequate den tist staffing and hours shall be provided to avoid unreasonable delays in dental care.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
15.a-b
This has moved up to partial com pliance only on the basis of plans for renovation of the dental unit. 2-4 hours of dental care a week is insuffi cient for this population of almost 1000 inmates. The program should consider contract dental services.
RECOMMENDATIONS:
1. Dental requests must be tracked in a manner similar to health service requests. 2. Patients with dental pain should not exceed a week in waiting. 3. Dental complaints with pain or inf ection must be evaluated by m edical staff pending an
appointment with the dentist. 4. Transportation officer issues must be corrected. 5. The dental unit must be rehabilitated to contemporary standards.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and re lated medical data, for every in mate who dies while in the custody of LCJ or under medical supervision directly from the custody of LCJ.
b. LCJ shall conduct a mortality review fo r each inmate death while in custody and a morbidity review for all serious su icide attempts or other inc idents in which an inmate was at high risk for death. Mortality a nd morbidity reviews shall involve physicians, nurses, and other relevant LCJ personnel a nd shall seek to dete rmine whether there was a patter n of symptoms that might have resulted in earlier diag nosis and intervention. Mortality and morbidity reviews shall occur within 30 d ays of the incident or death, and shall be revisited when the final a utopsy results are av ailable. At a minimu m, the mortality and morbidity reviews shall include:
(1) critical review and analysis of the circu mstances surrounding the incident;

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(2) critical review of the procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental hea lth services/reports involving the
victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plan t,
medical or mental health services, and operational procedures.
c. LCJ shall address any problems identif ied during mortality reviews through timely training, policy revision, and any other appropriate measures.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
16.a-c.
An autopsy is performed on every death. I was able to review the autopsy of the last death.
There is a policy which I was shown during the visit. It needs minor modifications but is a major improvement over the previous version. It can be simplified further so that the policy and procedure are not written as separate docum ents. Current diagnoses, m edications, and demographic data need to be included in the in formation which is collected on all deaths. Also, because everyone at the site in supervisory positi ons is probably involved in care of the patient, CHI should find an objective outside party to perform these reviews. The policy should state that the complete medical record will be reviewed as par t of the review. I discu ssed problems with the prior mortality review with leadership.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. A mortality review committee should be estab lished as part of the Quality Im provement Committee.
2. Mortality Review should be conducted by the Medical Director. In the event that there is a conflict with the M edical Director reviewing the case, an independent objective physician can perform the review.
3. Custody, mental health and medical should participate in these reviews. 4. The review should result in a docum ent that gives recommendations for im proving
aspects of care that were deficient as identified in the mortality review.

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B. MENTAL HEALTH CARE: Settlement Agreement Part III Section B

1. LCJ shall provide adequate services to addre ss the serious mental health needs of all

inmates, consistent with generally accepte d correctional standards o f care, including

sufficient staffing to meet th e demands for timely access to an appropriate mental health

professional, to ensure qualified mental he alth staff perform intake mental health

screenings and evaluations, and to pe

rform comprehensive assessments and

comprehensive multidisciplinary treatment planning. See Section III. A.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

October 2012 Assessment:

As of August 15, 2012, the QMHP FTE allocated positions were allocated as follows:

1.0 FTE 1.0 FTE 2.0 FTE 3.0 FTE 12.5 FTE

QMHP Clinical Director, Ph.D., LMHC, LMFT, LCAC QMHP Clinical Supervisor, LMHC, LCAC QMHPs LCSW, LMHC, LCAC QMHP-C (Candidates for LMHC and LCSW) QMHS, Crisis Stabilization/Suicide Counselors, B.S. or higher

The psychiatrists’ allocation will be further discussed in a later SA provision of this report (see section B.3.e.).

CorrecTek (CT) issues preventing the statistical analysis of the percentage of inm ates booked with a positive m ental healthcare screening have partially been reso lved, but there rem ains significant limitations—at least as the data is currently reported. For example, the current report summarizes on a m onthly basis the num ber of m ental health referrals generated through the screening process. However, the report does not distinguish between referrals generated due to suicide risk concerns versus ot her mental concerns (such as cu rrent need for treatment) and does not provide a summ ary for the reasons that vari ous referrals are no t completed in a tim ely manner. Some of this inform ation is availabl e via an individual char t review although this information has not been aggregated in a report format.

In general, it appears that the cu rrent staffing allocation is adequate f or LCJ to perf orm the required mental health screening process (if the ti meframes for routine referrals are changed) but not adequate to provide services to address the serious mental health needs of all inm ates for reasons that will be summarized elsewhere in this report.

October 2012 Recommendations for next 6 months:

1. Need a staffing analysis re: the number of FTE mental health positions necessary to comply with the various provisions of this Settlement Agreement.
2. Such an analysis shou ld be referen ced in the staffing policy and procedure to be developed as referenced in the next section.

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2. Timely and Appropriate Evaluation of Inmates.
a. LCJ shall develop and implement policie s and procedures to provide adequate screening to properly identify an d assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
During our April 2012 site visit the findings included the following:
Policies and procedures relevant to restraint/seclusion, special needs and services, inmate care and treatm ent, suicide preventio n program, governance and adm inistration and inmate care and treatment were reviewed with relevant staff and consultants.
Other policies and procedures, as previous ly summarized in the Septem ber 2011 report, still need to be developed and implemented, which include the following topic areas:
1. Mission and goal 2. Administrative structure 3. Staffing (i.e., job descriptions, credentials, and privileging) [staffing plan] 4. Involuntary treatment including t he use of forced medications, and involu ntary
hospitalization 5. Other medicolegal issues including informed consent and the right to refuse treatment 6. Limits of confidentiality during diagnostic and/or treatment sessions with pertinent
exceptions described 7. Mental health record requirements 8. Quality assurance and/or improvement plan 9. Research protocols
The recommended draft policies and procedures have not yet been completed.
Policies and procedures that had been revised a nd finalize since th e last site asses sment were reviewed which included the following areas:
Notification and review of an inmate deaths Receiving screening (mental health) Mental health evaluation Segregated inmates Basic mental health services Individualized Mental Health Treatment Planning Restraint (completed during site assessment)
During the site visit we again discussed issues related to the d raft restraint policy. I t was emphasized to LCJ staff that policies and procedur es relevant to restraint use for m ental health

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reasons needs to be operationalized in a healthcare policy that is sep arate from the correctional policy relevant to the use of restraints for security/correctional purposes.
October 2012 Recommendations for next 6 months:
1. Develop the previously referenced policies and procedures.
b. LCJ shall ensure that the in take health screening process referred to in Section III.A.2 includes a mental health screening, which shall be incorporated into the inmate’s medical records. LCJ shall ensure timely access to a Qualified Mental Health Professional when presenting sy mptoms of mental illnes s require such care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Since the last site a ssessment, there is no long er a ba cklog of inmates waiting for an in itial mental health evaluation.
Refer to section B.1 re: issues r elevant to an alysis pertinent to the m ental health screen ing process. As is apparent by reviewing the intake mental health asse ssment statistics, it is ver y clear that a very high percen tage (generally greater than 70%) of inm ates receiving m ental health/suicide prevention screenings are referred to mental health for further assessment. This is problematic from a screening perspective due to a very high false-positive rate that results in the use of scarce mental health resources. In additi on, there were a variety of issues related to m any of these assessments either not being completed or not being completed in a timely manner. The reasons for such problems had not yet been systematically assessed although it appears that some of the statistics were misleading. For example, some of these assessments were not completed in a timely manner because the inm ate had recen tly been sent to cou rt or the inm ate had been discharged from the facility prior to the timeframe expiring.
Another problem with the intak e mental he alth screening process, wh ich is perform ed by the nursing staff in the booking area, has to do with th e triage process in th e context of whether referrals are e mergent, urgent or routine. Th e mental health staff reported that it was not uncommon to have urgent and/or emergent referrals that shoul d have been triaged as being routine.
I spoke w ith Dr. Harman and Mr. Hayes concer ning the above issues and provided specific details concerning the nature of the data that should be gather ed, reviewed, and analyzed. W e also discussed issues related to both the threshold for making referrals based on the intake mental health screening and the triage process.

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October 2012 Recommendations for next 6 months:
1. Resolve issues relevant to the m anagement information system in order to be able to gather basic statis tics needed fo r both management and quality im provement purposes.
2. The intake m ental healthcare screening process needs to be revised from the perspective of raising the th reshold for referral to m ental health. The curre nt Settlement Agreement (B.3.a) has been mistakenly interpreted to require any positive mental health intake screening question to require a mental health referral. In addition, training needs to be provided to the nursing staff relevant to the above changes that will be m ade in addition to issues regarding the triag e concerning th e acuity of the referral.
3. After the recommendations in #2 have been im plemented, a QI should be perform ed relevant to both the initial hea lthcare screening and subsequent m ental health evaluations resulting fro m positive initial he althcare screening. Issues related to th e triage process relevant to the acuity of the referral should also be exam ined. The QI should determine the reasons for lack of compliance with m eeting Settlement Agreement timeframes in the context of emergent, urgent and routine m ental health referrals along with a corrective action plan as appropriate.
c. LCJ shall ensure that the men tal health intake screening process includes inquiry regarding:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as th e death of a family member or clos e
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency,
or similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
October 2012 Assessment: The mental health intake screen ing process continues to include inquiry regarding the above refe rence elements, which is unchanged from the previous site assessment.

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3. Assessment and Treatment.
a. LCJ shall ensure that any inmate who screens positively for menta l illness o r suicidal ideation during the intak e screening process, or who is otherwise referred for mental health services, receives a comprehensive mental statu s evaluation in a time ly manner fro m a Qu alified Mental Health Profession al (immediate for emerg ent issues, within 24 hours of referral for an expedited comprehensive evaluation, or 72 hours of referral for a ro utine comprehensive evaluation). The comprehensive mental health evaluation shall include a recorded diagnosis section, including a stan dard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic an d Statistical Manual of the American Psychiatric Association. If Qualified Mental Health Staff find a serious mental illness, they shall refer the inma te for appropriate treatment. LCJ shall r eview available information regarding any diagnosis made by the inmate's community or hospital treatment p rovider, and shall account for the inmate 's psychiatric history as a part of the assessment . LCJ shall adequ ately document the comprehensive mental status evaluation in the inmate's medical record.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Timeliness issues have already been addressed in prior sections.
During the April 2012 site visit, the following was reported:
Staff reportedly they were frequently not using the mental health evaluation form due to it being very unwieldy and related to past staff vacancies that created workload issues.
Although the form has not been revised since Ap ril 2012, training and s upervision have been provided to the line staff, wh ich has reportedly resulted in the forms being com pleted as required. The staff has provided na rrative responses to many of the sections on the mental health evaluation (MHE) forms. The training has been pr ovided via weekly training in-services and the supervision via regular review by the mental health director.
These measures have increas ed CorrecTek MHE completion rate to an overall 76 percent for suicide MHE referrals and 36 percent for non suic ide MHE referrals. Seventy-four (74) percent of SRA referrals were com pleted within 24 hour s (100% com pleted for those referred for an emergent (i.e., 3 hour tim eframe) suicide MHE, 62 percent for an urgent (i.e., 24 hr) referral. Sixty-two (62) percent of non-suic ide MHE 3 hour referrals were done within that tim e frame; 10% for 24 hr; and 57 percent for 72 hour.
The outcome m easures summarized above are th e underlying reason f or the need for a QI as summarized in B.2.b. in the context of the mental health screening/referral process.
When the recomm endations in B.2.b. have been successfully im plemented, consideration for submitting a proposal to DOJ for changing th e timeframe for com pletion of routine referrals

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would be appropriate.
October 2012 Recommendations for next 6 months:
1. Complete the recommended QI as listed in 2.b.
b. LCJ shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate referrals for specialty care and reg ularly scheduled visits with Qualified Menta l Health Professionals.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: During the prior April 2012 site visit, the following was noted:
Inmates with mental illness on the fourth floor currently do not have access t o group therapy treatments reportedly due to custody escort officers’ issues. Inmates in the locked down units reportedly do not have acce ss to out of cell mental health assessments, which are being done at the cell front.
Inmates on the fourth floor with mental illness in single cells are locked in their cells 23 hours per da y except f or those housed in G & B section on the fourth fl oor. These inmates generally have access to the dayroom areas about four hours per day. The lack of out of cell ti me for inmates in single cells was reportedly primarily due to the lack of programming space within the fourth floor.
As will be d escribed elsewhere in this repor t, line staff indicated that the y had poor access to inmates related to custody staff issues that included lack of adequate numbers of correctional officers for escort purposes.
Inmates in the B sectio n of the 4 th floor no longer have access to th e dayroom area due to a broken window, which m eans they are essentially locked down in their cells 23 hours per day due to reported custody concerns about their behaviors.
Improvement is no ted relevant to a ccess to th ese inmates by m ental health clinicians on an individual basis. For example, 4th floor patients are routinely br ought by correctional officers to the QMHP cris is, individual, SRA and MHE sessions. Correctional officers have been cooperative with implementing and maintaining an M-TH psychiatrist clinic schedule of inm ate movements. Inmates are seen individually with the psychiatrist who is assisted by a QMHS
However, group therapy continues to not occur. Th e reason cited is lack of correctional officer staffing to conduct m ovements. This negativel y impacts inmates who are housed long term on the mental health unit. It should be noted that groups ar e being provided on these units for nonmentally inmates for AA and NA purposes via community volunteers. Plans have been discussed to move the entire mental health unit to Z Pod, which is possible to accomplish within the next six months.

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Based on infor mation obtained from both c ustody and mental health staffs, the working relationships between the two staffs has improved but continues to be somewhat strained.
During the morning of October 10, 2012, I observed the m ental health rounding process on the fourth floor. One fe male inmate, who has been waiting for about one month for a state hospital bed to open up, has not showered for at least one m onth and had smeared feces on her windows three days earlier that had not yet been cleaned up. This inmate was well known to staff and was clearly a dangerous inm ate. However, the SORT team had not yet been called re: the above issues.
The mental health treatm ent being provided to inm ates with serious illness, especially on the fourth floor, is inadequate.
October 2012 Recommendations for next 6 months:
1. Despite space being available for group treatment, such groups are no longer occurring due to apparent custody issues/pract ices. These issues need to be resolved in order to allow for out of cell structured activities to occur.
2. Expedite the reported plan re: m oving of the m ental health unit to Z pod. The correctional officers assigned to such a un it should receive special m ental health training and be assign ed to the un it for at least six m onths until un less they clear ly demonstrate problems working on such a unit. Enhanced mental health staffing wil l be required in order to provide the necessa ry psychosocial rehabilitation treatment, which will be predominantly group and activity therapies.
c. LCJ shall ensure th at treatment plans adequately address in mates' serious mental health needs and that the pl ans contain interventions s pecifically tailored to the inmates' diagnoses.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: A treatment plan form has been developed as of August 28, 2012 but needs to be revised to be consisten t with the recently approved policy and procedure re: treatment planning. The policy and procedure re: treatment plans has not yet been implem ented. Training has started on im plementation of this policy. QMHPs ar e focusing upon “crisis stabilization” and “medication management” needs at the present time.
Audits indicated that a very rudimentary treatm ent plan i s being formulated for inm ates on suicide precautions.

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October 2012 Recommendations for next 6 months:
1. Continue training and implementation of the treatment plan policy and procedure.
a. LCJ shall provide for an inmate's reasonable privacy in mental health care, and maintain confiden tiality of inmates' me ntal health status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: Construction on a new intake screening area is pending- should be completed by December 2012.
Psychiatrist interviews inmates in his office on a regular basi s Monday through Thursday each week. A correctional officer (CO) is posted outside the door the entire time.
QMHPs regularly conduct individua l sessions in the 4th floor offices. Inm ates are escorted by correctional officers (COs). The MHE assessm ents in booking still involve privacy issues. Unless the referral is an emergent or urgent QMHPs attempt to postpone the M HE until th e inmates are placed in general population.
Cell-side assessments are conducted when the potential for harm to staff is evident or when COs will not op en the doo rs to cells. Space for ev aluating/treating inmates with ad equate sound privacy throughout LCJ remains problematic related to both space issues and correctional officer shortages.
October 2012 Recommendations for next 6 months:
1. Complete the construction of the new intake screening area. 2. Remedy the issues c ontributing to inadeq uate assessment/treatment space as
described above.
e. LCJ shall provide ad equate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see s uch inmates in a timely manner.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
My April 2012 recommendations included the followi ng: “Increase the psyc hiatric allocation to 1.0-1.5 FTE psychiatrists.”
Although there were 151 inm ates receiving psychotropic medications, only 78 of these inm ates had been evaluated by the psychiatrist. There was generally a 3-5 week wait for routine referrals

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to be seen by the psychiatrist.
It was estimated that approximately 200 inmates were on the mental health caseload at any given time.
Marcus Wigutow, M.D. continues to provide 16 hours per week of psychiatrist coverage. He is at the jail four days a week for 4 hours each day. He averages seeing 8-9 patients per day. A search for NPs with a psychiatric bac kground or certification was conduc ted by Dr. Harman the mental health director. Two possible candidates have b een identified. It was my understanding that a candidate has agreed to the position but there are bureaucratic obstacles delaying her start date.
The psychotropic medication management continues to be very problematic related, in part, the psychiatrist’s allocation issue previously referenced.
October 2012 Recommendations for next 6 months:
1. Increase the number of psychiatric hours at the LCJ, which can be partially done via a psychiatric nurse practitioner. The bureaucrat ic obstacles should be resolved as soon as possible in order to visit to facilitate hiring of this position.
f. LCJ shall ensure timely and appr opriate therapy, counseling, and other mental health programs for all in mates with serious mental illness. This includes adequate space for trea tment, adequate number of Qualified Mental Health Staff to provide trea tment, and an adequate array of structured therapeutic programming.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
My April 2012 assessment report included the following:
Except for the i mproved access to psy chiatric hospitalization, little progress h as been made relevant to this pr ovision of the SA. Treatment for mental health caseload inmates on the fourth floor consists of medication management and indiv idual counseling in an office setting with so me exceptions related to concerns re: potential violence. Structured out-of-cell group therapeutic activities are curren tly not being offered related to reported custody escort issues. Segregation inmates generally are not receiving counseling in a setting that allows for adequate sound privacy related to b oth physical plant i ssues and correctional officer staffing allocation issues.
Treatment provided to mental health caseload inmates is often negatively impacted by the lack of adequate correctional officer allocations and custody practices.

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Except for inmates on the f ourth floor, the predominant treatment for inmates receiving mental health treatment is medication management and counseling, as needed, in c ontrast to being seen on a regular basis.
See section 3.b. Very little change is present as compared to the prior site assessment.
Refer to section 3.j. for information relevant to access to inpatient psychiatric care.
October 2012 Recommendations for next 6 months:
Recommendations are essentia lly unchanged from my April 2012 report which included the following:
As stated in B.3.b., inmates with the most serious symptoms of a m ental illness are essentially locked in their cells 23 hours a day reportedly related to prim arily physical plant issues. Such restrictions are not only non-therapeutic but are likely to make many of these inmates clinically worse. The current physical plant is not appropriate for many of these inm ates with seriou s mental illnesses and alternative housing options [needs to occur].
An outpatient level of m ental health care need s to be m ore developed and im plemented in contrast to the treatment just being seen by the psychiatrist on an untimely basis.

g. LCJ shall ensure mentally ill inmates in segregation receive timely and appropriate treatment, including completion and doc umentation of regular rounds in the segregation units at least once per week by adequately trained Qu alified Mental Health Professionals in order to assess the serious mental health n eeds of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluat ed by a Qualified Mental Hea lth Professional to determine the inmate’s mental health status, which shall include an assessment of the poten tial effect of s egregation on th e inmate’s mental hea lth. During th ese regular evaluations, LCJ shall evaluate whether contin ued segregation is appropriate for that inmate, considering the assessment of the Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Recommendations in the April 2012 report included the following:
The mental health rounds process should involve the QMHP walking the segregation tiers cell by cell in order to “check-in” with each in mate. A mental health screening process should be implemented relevant to i nmates newly transferred to segregation h ousing

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units, which should be pe rformed in a confid ential manner in order to assess relevant mental health issues. A pr ocess should eventually be put in place relevant to assessing whether the inmate's disciplinary sanction might be mitigated by their mental illness.
The above recommendations have been incorporat ed into the “Segregated Inm ates” policy and procedure (5/29/12 updated) that w as implemented 9/12/12. However, this policy has not yet been completely fully implemented related to the need for training both m ental health and custody staff on relevant provisions of the policy and procedure. For exam ple, custody staff is usually not notifying mental health staff of new inmates admitted to the segregation unit.
A brief m ental status exam is being utilized to screen and assess the n eeds of MI and SMI in segregation. MSE and MHEs are conducted outside of the segrega tion cells in a holding area. This affords adequate p rivacy from other inm ates is prob lematic due to staf f traffic in th e immediate area.
During the first 8 months of 2012 there were 35 diffe rent trips to segregation for an average of 4 per month. Of the 340 inmates recorded as being placed in segregation, the QMHP found that 87 inmates were in need of mental health services. Thirty-eight (38) of these inmates met criteria for a serious mental illness. 3 inmates were previously on the mental health caseload prior to being placed in segregation. To date a significan t number of inm ates (13) have been moved off segregation to the 4 th floor due to th e mental illness. The major ity of the inmates with a ser ious mental illness had a diagnosis of schizophrenia.
The above data was reflective of a backlog in the context of the psychiatrist’s evaluations. It is encouraging that inm ates in segr egation who need to be on the fourth floor are identified and transferred. It is discouraging th ere were so m any of such inm ates admitted to th e segregation unit because it like ly reflects untim ely identification of inm ates with a m ental illness and/o r inadequate treatment.
I observed the m ental health rounding process in the segregation units during the morning of October 9, 2012, which was done in a competent manner.
October 2012 Recommendations for next 6 months:
1. A quality improvement study needs to be done relevant to timeliness of MHE’s being completed following re ferrals in a ddition to the nature of the treatm ent being provided following a positive MHE.
2. The “Segregated Inm ates” policy and procedure needs to be im plemented, with specific focus on custody staff notifying m ental health staff in a tim ely manner of inmates being admitted to the segregation unit.

h. LCJ shall maintain an updated l og of inmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive med ication. The log shall include each inmate's name, diagnosis or complaint, and next scheduled appointmen t. Each clinician

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shall have ready access to a curr ent log lis ting any presc ribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and a ccurate information regarding any medication changes ordered in at least the past year.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
CT issues have been resolved for tracking ps ychiatrist appointments, medication renewal, medications in MAR.
Dr. Harman reported that LCJ is now capable of maintaining an updated log of inmates receiving mental health services (which shall include both those inmates who receive counseling and those who receive medication), but has not yet p roduced such a list. Related to both staffing allocation and management information system issues, inmate s are not the m ental health caseload regular follow-up except on the fourth floor.
In order to mitigate problems associated with not having an outpatient mental health cas eload, two QMHPs have been assigned to specific PODS to encourage MH utilization.
Although 2 counseling offices have been identif ied for individual counseling on the 3rd and 5 th floors, inadequate CO coverage prevents using the offices at this time.
October 2012 Recommendations for next 6 months:
1. A current log of inmates receiving mental health services should be readily available. This log should include diagnoses and needed level of m ental health care, both of which are necessary for system planning purposes.
i. LCJ shall ensure that a Qualified Me ntal Health Professional conducts an in-person evaluation of an inmate prio r to a medically-or dered seclusion or restraint, or as soon th ereafter as possible. Patients placed in med icallyordered seclusion or restraints shall be evaluated on an on-going basis for physical and mental deterioration. Seclusion or restra int orders sh ould include sufficient criteria for release.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: The restraint policy has not yet been finalized. Further input was provided during this site assessm ent as referenced in th e policy and procedure section of this settlement agreement.

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October 2012 Recommendations for next 6 months:
1. Finalize and implement the restraint policy.
j. LCJ shall ensure an adequate array of crisis services to appropriately manage the psychiatr ic emergencies that occur among inmates. Crisis services shall not be limited to ad ministrative segregation or observ ation status. Inmates shall have ac cess to ap propriate licensed in- patient psychiatric care, when clinically appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Policies and Procedures entitled “Involuntary Commitments” have been implemented to ensure inmates with a serious mental illness who need long term placement are evaluated and placement secured with the cooperation of the court system.
A good working relatio nship with Regional Mental Health and the court system is in place to provide evaluations for state hospitalization, resi dential placement in the comm unity as well as follow care for the res pective catchment areas of NW, NE and the southern region of Lake County.
Edgewater Systems continues avoid a working rela tionship with LCJ. The Sheriff and MH staff have developed a working relationship with Ga ry City Court (Judge Didre Monroe) and the County Court System (Judge Parras) to m andate Edgewater to participate in the process. Edgewater’s cooperation for actual placements after the evaluations of patients remains resistant.
In the tim e between evaluation a nd placement, the cou rts have be en willing to m andate medication for inmates with a se rious mental illness to prevent harm to self and others as an attempt to stabilize the patients before placement. Th is stabilization/medication measure has proven effective pending placement in a number of cases at LCJ.
The court has appointed an attorney to work with LCJ to access the care needed for inmates with a SMI. 13 inmates with a SMI have been placed within the state system in 2012.
October 2012 Recommendations for next 6 months:
1. Continue to find a rem edy to the above desc ribed problem with lack of access to an inpatient psychiatric hospitalization for inmates in the Edgewater Community Mental Health Center catchment area.

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4. Psychotherapeutic Medication Administration
a. LCJ shall ensure th at psychotherapeutic medication administration is provided when appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Policies and procedures relevant to this issue still need to be developed.
Staffing allocations for psychiatrists’ time remain inadequate as previously discussed.
QI studies relevant to m edication management issues were currently lacking. A case conference approach has been used to address medication prescribing practices.
Psychotropic medication utilization has decrea sed during 2012 related to case discuss ions, implementation of a formulary and supervision. Review of a sm all number of healthcare charts indicated poor documentation by the psychiatrist and untimely appointment with the psychiatrist.
Staff described significant cont inuity of m edication issues su ch as m edications not being renewed in a tim ely manner and m edication noncompliance frequently being reported in an untimely fashion by nursing staff.
Discharge medications are not provided to inmates discharged from the jail.
October 2012 Recommendations for next 6 months:
1. QI studies need to be perform ed re: medication management issues with specif ic reference to continuity of medications.
b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physicia n on a regular, timely basis for a ppropriateness or adjustment. LCJ shall ensure that changes to inmates' psychotropic medications are clinically justified and documented.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
My April 2012 report included the following:
The previously recommended policies and procedures relevant to medication administration should include a polic y addressing medication noncompliance, required laboratory testing and continuity of medication issues.

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As referenced in other sections of this report, review of inmates’ psychotropi c medications by a psychiatrist or physician on a regular, ti mely basis for appropriateness
or adjustment was problematic.
Review of current healthcare records demonstrated similar issues.
The psychiatrist’s allocation remains at 16 hours per week. A sear ch for NPs with a psychiatric background or certification was conducted by Dr. Harman the m ental health director. As previously summarized, bureaucratic obstacles are delay ing the hiring of a psychiatric nurse practitioner.
October 2012 Recommendations for next 6 months:
1. At the present tim e, continue with the cas e conference form at although this type of review should be via QI process in the future.
c. LCJ shall ensure time ly implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated with psychotropic medications are seen regularly by a physician to monitor responses and potential reactions to th ose medications, including movement disorders, and provide treatment where appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
See 4. a., b., & c. Also see report by Michael Puisis, D.O.
As previously referenced, policies and procedures need to be developed relevant to this provision of the SA. Audits have not been done re: medication administration.
October 2012 Recommendations for next 6 months:
1. Develop the relevant policies and procedures and audit implementation.

C. SUICIDE PREVENTION: Settlement Agreement Part III Section C.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and pro cedures to ensure the appropriate management of suicid al inmates, and establish a suic ide prevention program in accordance with generally accepted correctional standards of care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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October 2012 Assessment: QMHPs and QMHSs have co mpleted in-service training on S.P. policies. Follow up with patients rem oved from precautions is lo gged and tracked fo r compliance at 24 hr, 72 hr. and 7 days.
After the initial 24 hours patients are re-assessed (SRA) for the appropriate return of privileges (paper, reading m aterials, regular bedding and uni form, etc. Psychiatrist is consistently consulted before orders are rescinded.
QI reports indicates for January 1 through A ugust 31, 2012 - 97 percent of 9965 jail adm issions between January and August 2012 were com pleted. Approximately 70 percent of all adm issions were referred for either SRA or M HE (1% for suicide prevention and 68% for non suicide). 91 percent of all SRAs referred were com pleted, 74% within the 24 hour requirem ent. Regarding MHE referrals, 76 perc ent were co mpleted for suicide M HE referrals and 36 percent for no n suicide MHE referrals. 74 percen t of SRA referrals were com pleted within 24 hours, 100% referred for 3 hour suicide MHE we re completed within 3 hrs; 62 percent for 24 hr referral, and 100% for 72 hr referral.
To be in substantial compliance with this provision of Settlement Agreement, all other provisions relevant to suicide prevention in the SA need to be found in substantial compliance.
October 2012 Recommendations for next 6 months:
1. As per the recommendations in the following sections of this report.
b. The suicide prevention policy shall in clude, at a minimu m, the follo wing provisions:
(1) an operational description of the requirements for both pre- service and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
October 2012 Assessment: The mental health staff continues to utilize the procedu res outlined in policy. Adm inistrative Coordinator and Clin ical Supervisor monitor compliance. Clinic al Supervisor is directly involved in treatment of patients on suicide precautions. Log book is kept tracking MHE and follow up sessions.
No change since the previous April 2012 assessment.

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c. LCJ shall ensure suicide prevention po licies include pro cedures to ensure the safe housing and s upervision of in mates based on the acuity of their mental health needs.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
October 2012 Assessment: As of April 2012 the MH Director no longer required to provide coverage for vacant QMHS position s on the midnight shift. A m inimum of two QMHS provide coverage 7 days a week for all three shifts. As a result, COs are not required to provide close or constant observations due to unavailability of QMHS.
An audit of healthcare records of 8 inmates placed on suicide precautions was co mpleted by Lindsay Hayes, M.S. Results included the following
Pursuant to Provision C.1.c of the DOJ Settlement Agreement (which requires safe housing and supervision of inm ates on suicide precautions), Observation Sheets that document the required o bservation of inmates on suicide precautions were randomly reviewed while inm ates were on Close Observation status. All were found to be accurate and u p-to-date. This is an excellent practice and QMHS/CST staff should be commended fo r their hard work. (During the previous audit, there were several exam ples of missed checks due to inadequate QMHS/CST staffing. The program is now at full staffing and this problem has been resolved.)
The audit r esults were consistent with m y observations during the site visit of inm ates on precaution on the fourth floor.
d. LCJ shall ensure security staff posts in all housing units a re equipped with readily available, safely secured, suicide cut-down tools.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
October 2012 Assessment: Sustained compliance remains
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
October 2012 Assessment: Substantial compliance continues.

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f. LCJ shall document inmate suic ide attempts at LCJ in an inmate's correctional record in the cla ssification system, in order to ensure that intake staff will be aware of past suicide attempts if an inmate with a history of suicide attempts is readmitted to LCJ.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
October 2012 Assessment:
Once suicide precaution orders have been ini tiated, a co lored screen pops up anytim e the inmate’s EMR is accessed. CT issues have been resolved. Clinical Supervisor monitors CT order for pop up continues.
LCJ has interpreted this provision as follows:
We believe that th is provision is meant to require that when an inm ate is readmitted into the jail, that medical and/or mental health staff are aware at intake of any prior suicide attempts within the facility and consid er such inform ation during the intake screening process. We have made several changes to CorrecTek and a pop-up screen has been installed th at automatically notifies the user (e.g., intake nurses) that the inm ate was on suicid e precautions during a previous incarceration. The pop-up screen includes th e date of suicide precautions. This notification cannot be deleted from CorrectTek. The notification not only includes prior suicide attempts, but more importantly, placement on suicide precautions for a variety of reasons, including suicidal id eation, gestures, m ental health status outside normal limits, etc. the most recent QI audit (which should be finalized and to you m id-week) confirms that the pop- up screen appeared on all reviewed records of inmates with prior histories of suicidal behavior in the jail.
The previously referenced audit by Mr. Hayes f ound that in all the revi ewed cases of inm ates who were placed on suicide precautions during a previous LCJ confinement and then readmitted into the facility, there was a pop-up screen on CorrecTek that alerted staff of this prior history.
I am in agreement with the above interpretation and findings.
2. Suicide Precautions.
a. LCJ shall ensure that suicide p revention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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October 2012 Assessment:
Administrative Coordinator review s all obs ervation logs for com pliance and signs and documents date for each observatio n sheet. SP Policy update rep laced EMT language with RN and 10 minute checks changed to 15 minutes.
An audit of healthcare records of 8 inmates placed on suicide precautions was co mpleted by Lindsay Hayes, M.S. Results included the following:
Pursuant to the DOJ S ettlement Agreement (which requires safe housing and supervision of inmates on suicide precautions), Observation Sheets that document the required observation of inm ates on suicide precautions were random ly reviewed while inmates were on Close Ob servation status. All were found to be accurate and up-to-date. During the previous audit, there were seve ral examples of missed checks due to inadequate QMHS /CST staffing. The program is now at full staffing and this problem has been resolved.
The above findings were consistent with my checks during the site assessment.
b. LCJ shall ensure that when staff in itially place an inmate o n Suicide Precautions, the inma te shall be searched and monitor ed with consta nt direct supervision until a Qualif ied Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Until such an assessme nt, inmates shall be placed in gowns recommen ded and approved for use with suicidal patients.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
Clinical Supervisor has taken an a ctive role in working with QMHPs to re-assess and allo w appropriate items.
Allowable items are listed on the to p of the observation sheets and docum ented in patient’s CT record with supporting evidence when restrictions apply.
Some resistance remains from COs who state “s uicide is suicide risk” and do not want to offe r any items. Clinical Supervisor consulted Lind say Hayes and the Warden sent a directive on 7.23.12 to all LCJ staff that IMs could receive the appropriate item s while on precau tions, especially toilet paper.
An audit of healthcare records of 8 inmates placed on suicide precautions was co mpleted by Lindsay Hayes, M.S. Results included the following from one of the records reviewed:
The following day (September 5), a QMHP attempted to ass ess the inmate in the morning and complete a MHE. A progress note stated that “attempted to complete

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MHE. The inm ate could not be pulled for evaluation because of operational conditions in his sectio n. He will n ot be available for the rem ainder of the day because visitation for W -Pod will be beginning soon. Follow-up ASAP.” Later that evening, a correctional officer called mental health staff after the inm ate threatened suicide. He was seen by a QMHS and reported anxiety, depression, and suicidal ideation (w ithout a plan). A progress note indicated that the officer would attempt to relocate the inmate to another housing unit, and the QMHS would refer the inm ate to the psy chiatrist. Despite expressing suicidal ideation, the inmate was not pla ced on suic ide precautions pending an evaluation by a QMHP.
The above process was not consistent with this provision although the aud it results appeared to indicate that this practice was an exception rather than the usual practice.
October 2012 Recommendations for next 6 months:
1. Continue to monitor.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified Medical or Mental Hea lth Staff shall write orders setting forth the conditions of the watch, including bu t not limited to allowable clothing, property, and utensils. These con ditions shall be alter ed only on th e written instruction of a Qualified Mental Heal th Professional, except under emergency circumstances.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment:
An audit of healthcare records of 8 inmates placed on suicide precautions was co mpleted by Lindsay Hayes, M.S. Results included the following:
Pursuant to Provision C.2.c of the DOJ Settlement Agreement (which requires written justification for allowing/prohibiting clothing, property, and utensils when an inmate is on suicide precautions), the current practice of the clinical supervisor is to require rem oval of cl othing/issuance of a safety smock and denial of other privileges such as sho wer, telephone call, vis it etc. in all cases for the first 24 hours of suicide precautions. Although this might be viewed as overly cautious, it is not necessarily problem atic if it is lim ited to 24 hours before reassessm ent. In addition, although most of the reviewed cas es in this audit involved inmates who were on su icide precautions for on ly 24 hour s or less, in thos e cases in which inmates were held on suicide precautions for more than 24 hours, there was no documentation to justify continued prohibi tion of clothing and privileges, and it would appear that these inm ates were deni ed these item s, regardless of level of risk and length of stay on suicide p recautions. As previously noted, only one of the reviewed cases involved an inmate on su icide precautions who was reis sued

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their clothing and per mitted a sh ower, the r esult of which apparently was confusion amongst m ental health staff as to whether the inm ate was still on suicide precautions (see Case T.T.). Finally, a previous problem of some inmates being denied a mattress and/or toilet paper without justification was resolved with intervention from the LCJ Warden in July 2012.
I am in agreement with the above findings.
October 2012 Recommendations for next 6 months:
1. Train staff re: this provision and re-audit.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Staff shall assess and interact w ith (not just observe) inmates on Suicide Precautions on a daily basis.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: QMHPs interact and re-assess patients using SRA daily. In May 2012 QMHP scheduling was changed to include coverage on Saturdays and Sundays to meet this requirement.
The audit by Mr. Hayes included the following findings:
Re: Case JN
In sum, there were several issues noted, in cluding the fact that 2 S RAs were completed within 20 minutes of each o ther on July 8, and requ ired follow-up assessments post-discharge from suicide precautions were not always provided. The inmate had been refusing his psychotropic medication for almost a month and had not been seen by any m ental health staff in almost 2 months. The treatm ent plan was problematic.
Re: Case DD
In sum, although m ost follow-up assessm ents post-discharge from suicide precautions were tim ely, others were not . Several daily ass essments by QMHP staff were not perform ed while the inm ate was on suicide p recautions. Multiple MHEs were completed (and only one was necessary). Two SRAs were completed on the same day in close proxim ity to each other. The treatm ent plan(s) was problematic. Segregation rounds were timely and the Brief Mental Health Assessment for Segregation was completed as required.

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Re: Case DL
In sum, all intake screening, SRAs, and MHE forms were com pleted on tim e pursuant to policy. One of the daily QM HP assessments was not perform ed and only one post-discharge suicide precautions follow-up assessment was done (and it was late). The treatment plan was problematic.
As per the above findings, problems continue re: daily and post discharge follow-up, which was not consistent with log data.
October 2012 Recommendations for next 6 months:
1. Train/supervise staff re: this provision.
2. The Clinical Supervisor should determ ine why the current L og Book maintained to track inmates on suicide precautions, as well as required post follow-up assessments, is not always accurate based upon the findings from this audit.
e. LCJ shall ensure that inma tes will only be removed from Suicide Precautions after approval by a Qua lified Mental Health Professional, in consultation with a psychiatrist, af ter a s uicide risk assessment indicates it is saf e to d o so. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: I was unable to determ ine, based on the audit by Mr. Hayes, whether the element of this provision involving consultation with the psychiatrist was followed.
October 2012 Recommendations for next 6 months:
1. Audit all the elements of this provision.
3. Suicide Risk Assessments.
a. LCJ shall ensure that any inmate s howing signs and symptoms of suicide is assessed by a Qualified Mental Health Professional usin g an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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October 2012 Assessment:

QMHPs have received docum ented training rega rding use of SRA. Log utilized to track compliance. QMHP and QMHS assigned to monitor compliance.

The audit by Mr. Hayes indicated that all intake screening, initial SRAs, and MHE forms were completed on time pursuant to policy.

October 2012 Recommendations for next 6 months:

1. Continue to monitor.

a. LCJ shall ensure that the risk assessment shall include th e following and findings from the risk assessment shall be documented on both the assessment form and in the inmate’s medical record:

i. description of the antecedent events and precipitating factors; ii. suicidal indicators; iii. mental status examination; iv. previous psychiatric and suicide risk history; v. level of lethality; vi. current medication and diagnosis; and vii. recommendations or treatment plan.

OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

October 2012 Assessment:

As of May 2012 QMHPs utilize SRA for init

ial assessments and re-assessment when

determining continued use of precautions. See SRA in CT.

Except for one case, compliance with this provision was consistent with the audit performed by Mr. Hayes.

October 2012 Recommendations for next 6 months:

1. Continue to monitor

4. Suicide Prevention Training.

a. LCJ shall review and, to the ex tent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:

i. the suicide preventio n policy as revised consistent with th is Agreement;
ii. why facility environments may contribute to suicidal behavior;

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iii. potential predisposing factors to suicide; iv. high risk suicide periods; v. warning signs and symptoms of suicidal behavior; vi. observation techniques; vii. searches of inmates who are placed on Suicide Precautions; viii. case studies of recent suicides and serious suicide attempts; ix. mock demonstrations regarding th e proper response to a suicide
attempt; and x. the proper use of emer gency equipment, including suicide cut-down
tools.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
October 2012 Assessment:
Sustained compliance continues.
Based on the Hayes’ audit results, LCJ reported the following:
Pursuant to Provision C .4.b of the DOJ Settlement Agreement (which requires annual suicide prevention training for all LCJ personnel, the current suicide prevention policy (16.07.05: Suicide Preven tion, effective July 2011) is being slightly revised to include a protocol for the immediate reassessment of in mates on suicide precautions who are released from custody while still at risk for suicide. Upon completion of the revised policy, the suicide prevention curriculum will be rev ised to inc lude the new protocol a nd the annu al suicide prevention training will commence (estimated by the end of 2012).
I agree with the above plan.
b. Within 12 months of the effective dat e of th is Agreement, all LCJ staff members who work with inmates sh all be trained on LCJ's suicide prevention program. Staff shall demons trate competency in the verbal and behavioral cues that indicate pot ential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
October 2012 Assessment:
Newly hired m edical staff and co rrectional officers receive the same training and m aterials originally developed by Lindsay Hayes. Clin ical Supervisor conduc ts the trainings in cooperation with Training Officer. See training records for compliance.

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D. FIRE SAFETY: Settlement Agreement Part III Section D.
Overall Comments: In general, I continue to see im provements in all of these areas : Fire Safety; Sanitation and Environm ental Conditions; and P rotection From Harm. The m ost significant issues th at need to be addressed in order to ach ieve substantial compliance in the above areas of the SA ar e to obtain the proper sta ffing levels of correctional staff in order to be able to properly supervise the housing units, perfor m the necessary housekeeping and sanitation duties and to be able to provide adequate laundry services. E qually important is to have a sufficient number of correctional staff to ass ist medical and m ental health care staff in supervising and escorting inm ates to and from the housing units. Lake County officials have reported that they will author ize an additional 18 correctional officer position s in the 2013 budget which are in addition to th e previously added 12 correctional officer pos itions. This is certainly a step in the right directio n. Du ring this tour, D OJ Attorney William Maddox and I toured and inspected the Lake County W ork Release Center. The Work Release Center houses both male and f emale inmates in separa te areas of the f acility. Overall, we f ound the W ork Release Center to b e neat, clean and orderly a nd properly staffed. The W ork Center is selfsustained from the oth er LCJ Jails with the ex ception of the m edical and m mental health program which is administered from the main Jail. The facility has its o wn Director and staff. The facility has its own food serv ice preparation and feeding area. The facility is equipped with fire extinguishers and AED’s as well as other fire and safety features. The only recommendation made to staff was to make available “cut down” tools in strategic areas of the facility.
1. Fire Safety.
a. LCJ shall develop an d implement a comp rehensive fire safety pro gram and ensure compliance is appropriately docum ented. The initial fire safety plan shall be approved by the State F ire Marshal or the Crown Point Fire Chief o r Inspector. The fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever is sooner.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of fire safety related documents, staff interviews and personal observations, I found that LCJ continues to make considerable progress in the development and implementation of a comprehensive fire safety program. The written comprehensive fire safety program has been developed and implemented that includes: a fire safety policy and procedure; a location guide; fire safety forms; a training schedule; a training component; a written test; a

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practical test; and information regarding fire extinguisher maintenance. The fire safety plan also includes an inspection process and record keeping requirements. The full-time Fire Safety Officer for LCJ has substantial training and experience in fire safety matters. The initial fire safety plan was reviewed and approved by the Crown Point Fire Inspector on March 29, 2012. The fire safety plan will need to be reviewed by the Crown Point Fire Inspector in March 2014 or sooner if any revisions are made to the fire safety plan.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County Jail staff should include the Cr own Point Fire Department crew in some of their evacuation drills as recommended by the Fire Inspector in his March 29, 2012 letter to Lake County.
2. Lake County staff should continue to m aintain the fire safety standards they have achieved.
b. LCJ shall ensure that compreh ensive fire drills are conducted every three months on each shift. LCJ shall documen t these drills, including start and stop times and the number and location of inmates who were moved as part of th e drills.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of documents and interviews with staff and inmates, I found that the facility has developed a comprehensive fire drill program for the jail. LCJ staff continue to make improvements to the fire drill program. In April 2012 a full-time Fire Safety Officer was appointed. The Fire Safety Officer is charged with the responsibility for ensuring that the fire drill schedule is fully implemented. However, in order to achieve substantial compliance with this paragraph of the SA, Lake County staff will need to ensure that comprehensive fire drills are conducted every three months on each shift as well as documenting the start and stop times and the number and locations of inmates who were moved as part of the drills. The start and stop time of fire drills are being documented; however, in order to ensure that the fire drill program is comprehensive, additional fire drills must be completed in order to cover all areas of the facility.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County staff need to ensure that they stay on schedule with re spect to their fire drill program as well as expanding the f ire drills to all areas of the facility in the fire drill schedule.
2. During the next com pliance visit I will be reviewing the f ire drill sch edule and th e results of the documented fire drills.
c. LCJ shall ensure that LCJ has adequat e fire and life safety equ ipment, including installation and mainte nance of fire alarms and smoke detectors in

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all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
All of the housing areas and other areas of the facility are equipped with fire and smoke alarm systems. Maintenance and storage areas are equipped with fire sprinklers as well as food service areas. Facility staff continue to ensure that AED’s and SCBA’s are present in strategic areas of the jail and are being inspected. There were fire extinguishers available in all areas of the jail.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to adequately m aintain their fire and life safety equipment as required by this paragraph of the SA.
d. LCJ shall ensure that all fire and life saf ety equipment is properly maintained and routinely inspected.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of documents and staff interviews, I found that LCJ staff have continued to conduct inspections of all fire and life safety equipment as well as ensuring it is properly maintained. The LCJ Fire Safety Officer continues to serve on a full-time basis and oversees the fire safety program. The duties and responsibilities of the Fire Safety Officer, including the provisions of this paragraph of the SA were approved by the Sheriff on May 2, 2012.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to conduct inspecti ons of all fire and life safety equipment and ensure it continues to be properly maintained.
e. LCJ shall ensure that emergency keys are appropriately marked an d identifiable by touch a nd consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
Facility staff continue to work in developing and implementing a system for emergency key management. The emergency keys have been inventoried. Emergency keys have been placed in all facility control rooms and the radio room. The number of emergency keys assigned to each key ring is manageable. An emergency set of keys has been placed in the Sheriff’s Communication Center which is located outside of the Jail. A system of identifying emergency keys by touch has not yet been developed, but LCJ staff are reviewing various options for complying with this requirement. LCJ staff have developed and implemented a Key Control policy and a key inspection program. LCJ staff are still working on numbering all facility doors in order to match them with the proper keys. Once this process is completed and staff become familiar with the evacuation process, staff will need to be trained in the use of the emergency keys. Training for staff on the key control system is incorporated into the fire safety training program. The training supervisor reported that they are approximately 37% of LCJ staff have been trained on the fire safety program and policies; however, staff need to ensure that the training program incorporates the current fire safety policies and practices. LCJ staff have developed a “chit” system for maintaining accountability of the facility keys, which is a good correctional practice. However, the number of keys assigned to each key ring still needs to be developed. A master inventory of the facility keys was revised in October 2012 and needs to be maintained and updated as needed.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff need to develop a system of identifying emergency keys by touch. 2. The overall key control progr am needs to b e audited on a frequent basis by the
Facility Fire Safety Officer and the Fire Saf ety Compliance Inspector due to the f ire safety implications the key control program has in the overall fire safety program. 3. Jail staff need to contin ue to be trained in the use of e mergency keys as part of the pre-service and in-service staff training program and ensure that the cu rrent policies and practices are incorporated into the training program.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual overrid e in the event of an emergency in which the manual override is broken), including in th e event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. LCJ shall conduct regular security inspections and provide ongoing maintenance to security de vices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
During the inspection, jail staff continue to be knowledgeable on how the manual door unlocking system operates. During the tour I inspected and tested several locking mechanisms and doors and all were operable. LCJ staff have developed and implemented a door inspection policy. Staff are now conducting proficiency audits of staff in conjunction with fire safety drills; however, this process needs to be formalized and these audits need to be conducted on all shifts at least three times per year. The fire safety staff have developed a “Manual Unlocking Mechanisms Quarterly Test” schedule which is very helpful in tracking this requirement. It appears that the Fire Safety Officer is the primary staff member who coordinates this effort; however, the evening and night shift security supervisors could also be conducting these types of random audits and report the findings to the Fire Safety Officer as well as generating maintenance work orders on any needed repairs that may be identified. The reports generated by the Fire Safety Officer regarding these types of inspections are good and are starting to identify discrepancies in the system.
RECOMMENDATION FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to conduct formal random audits for testing staff proficiency in perform ing manual unlocking of all doors with the use of m anual override system. The results of these audits should continue to be documented.
2. Security supervisors in the evening and ni ght shifts can help supplem ent the random audits and report the findings to the Fire Safety Officer and Maintenance Department.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR NEXT TOUR:
I would like to continuing reviewing docum ents that demonstrate the res ults of the inspections/audits that were conducted for the emergency unlocking system and staff response as well as the follow-up maintenance repairs.
g. LCJ shall imple ment competency-based testing for staff regarding fire and emergency procedures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
With the assistance of the Crown Point Fire Inspector, LCJ staff have developed a training curriculum for fire and emergency procedures. Staff have started to receive training in fire and emergency procedures. LCJ staff reported that approximately 37% of the required staff were trained in July 2012 and another training class is scheduled for October 2012.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff s hould ensure that com petency-based testing for staff regarding fire and emergency procedures continues to be provided.

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h. LCJ shall ensure that fire sa fety officers are trained in fire safety an d have knowledge in basic housekeeping, emer gency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ has a full-time staff member to serve as the facility Fire Safety Officer. The duties and responsibilities for this position were articulated in writing by the Sheriff on May 2, 2012. The duties and responsibilities for this position are included as part of the fire safety plan. The person appointed for this position has an extensive background in fire safety and emergency management. She is a certified fire fighter and has attended numerous trainings in emergency management.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The LCJ Fire Safety Officer should continue to avail herself of available training on fire safety, basic housekeeping, em ergency management, the basic applicable codes , the use of fire extinguishers and other emergency equipment.
E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping a nd sanitation plans to ensure the proper routin e cleaning of housing, shower, and medical ar eas. Such polic ies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ continues to implement some components of their housekeeping and sanitation plans. LCJ needs to obtain final approval from the Sheriff and Jail Administrator on the overall sanitation plans and policies and procedures, including the sanitation inspection forms. Some of the inspection forms have been developed and are being utilized; however, the daily inspection forms for unit officers have not yet being implemented, primarily due to staff shortages. The sanitation officers continue to perform monthly sanitation inspections as well as being involved in special housekeeping projects such as removing graffiti from walls, cleaning out pipe chases and power washing various areas of the jail. Sanitation staff have also continue to be involved in

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replacing shower curtains. Housing unit and booking cell vents were much cleaner this tour than in past tours. A professional outside company was hired to clean many of the facility vents that were evident during the tour; however, this is an on-going process that needs to continue to be part of the overall cleaning and sanitation program. Sanitation in the medical area continues to improve generally; however, more emphasis needs to be applied to the patient cells, particularly in the mental health areas and the shower areas. In general, the booking area was neat clean and orderly. LCJ staff have intensified the cleaning and sanitation program in the booking area. However, a cleaning program cannot be sustained without sufficient staff to provide adequate inmate supervision within the housing units and for the inmate work crews.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to implement their written housekeeping and sanitation plans for the jail as well fully implementing the inspection program.
2. LCJ staff must ensure that the housing un it inmate workers and inm ate work crews are adequately supervised by detention staff at all times.
3. LCJ staff need to intensify the cleaning progr am in the medical area, especially in the patient cells and showers.
b. LCJ shall implemen t a preventive ma intenance plan to respond to routine a nd emergency maintenance needs, including ensuring that shower, toilet, and s ink units are adequately maintained and installed.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ staff continues to make strides in refurbishing the physical plant and making needed repairs to the plumbing system, including the shower areas and cell plumbing. During the tour, I did not observe roof leaks. There are continuous painting projects underway. The lighting system was in a good state of repair. A work order process continues to be in place and work orders can be tracked. LCJ staff are in the process of developing an automated system for the tracking of facility work orders and expects the program to be functional by early 2013. The automated system will also include a preventative maintenance component.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to conduct needed re pairs to the physical plant and plum bing system.
2. LCJ staff should fully im plement their written preventative m aintenance plan including the schedules for preventative m aintenance inspections and repairs, staff assignments that are responsible for inspecti on and repairs, a desc ription of the work order system and an inventory of regularly needed spare parts and plumbing fixtures.
3. The above requirements should be addressed in a facility policy and procedure.

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c. LCJ shall ensure adequate ventilation throu ghout LCJ to ensure that inmates re ceive an adequate supply of airflow and reasonable levels of he ating and cooling. LCJ shall review and assess comp liance with this require ment at lea st twice annually.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I observed that several inmate cells had the air vents covered with materials thus obstructing air flow. With limited floor officers it is difficult to maintain control over inmate cell vent coverings. I also observed that in many of the housing unit dayroom areas the return air flow vents were much cleaner and free of lint and debris. LCJ staff also hired an outside contractor to help clean the difficult to reach vents. In order to maintain the ventilation system clean, it requires intense cleaning and staff supervision over the inmate crews that are performing these types of tasks. However, if detention officers are not available in the housing units to properly supervise inmates, it will be difficult, if not impossible to attain and maintain substantial compliance with the requirements of this paragraph. The facility is doing a good job with the assistance of Johnson Controls in monitoring the airflow and heating and cooling system. Facility staff are able to readily monitor these systems through the use of an automated tracking and reporting system.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should continue to intensify their efforts to ensure that cell vents are not covered by the inmates. This can be partly accomplished by conducting daily cell sanitation inspections. However, there m ust be sufficient numbers of detention officers available in the housing units in order to accomplish these tasks.
2. Maintenance and the environm ental vendor staff should continue to keep records of temperature readings of the housing units and other areas of the jail.
3. The return air vents in the housing unit da yrooms should be regularly cleaned and made free of debris as part of the on-going and preventative maintenance program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
During the next tour, I will be reviewing LCJ efforts in attaining adequate staffing levels for providing supervision within the inmate housing units and over the inmate work crews.
d. LCJ shall ensure adequate lighting in all inmate housing and work areas and cover all light switches with exposed wires.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
During this inspection I did not detect problems with the lighting system. LCJ staff continue to work diligently on making repairs to the lighting system and replacing light bulbs and fixtures. I did not detect any exposed wiring during my inspection. Lighting in inmate cells and dayrooms was adequate.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to m aintain the lighting and electrical system in a good state of repair. For sustai nability purposes, LCJ staff should m ake the inspection of the lighting system part of their da ily housekeeping inspection program and preventative maintenance program.
e. LCJ shall ensure a dequate pest contro l throughout the housing units, medical units, and food storage areas.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection of inmate housing units, program areas, the food service department, the medical area and general areas of the Jail, I did not detect a problem with pest control. LCJ continues to maintain pest control services that provides for regular inspections and pest control.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue with their pest control program.
f. LCJ shall ensure that all in mates have access to needed hygiene supplies.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I did not observe a problem in this area. Inmates had in their possession needed hygiene supplies, both at intake and in the housing units. LCJ staff continue to maintain a significant amount of hygiene supplies in storage areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to issue inmate hygiene supplies at intake to inmates and as needed. 2. Include in the revised Inm ate Handbook hygi ene issue quantities and f requency of
issue.

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g. LCJ shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. LCJ shall ensure that any inmate or staff utilized to clean a biohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
There still does not appear to be a comprehensive coherent policy and procedure that addresses this area of operation. There are several policies that in part address this area. I observed during this inspection that spill kits continue to be made available in various areas of the facility. I also observed in the medical area (exam rooms) that biohazard containers with enclosures were available. I also observed that in the biohazard room in the medical area, the containers with biohazard materials were not properly covered with lids. LCJ staff reported that a training program is currently under development for addressing the requirements of this paragraph of the SA. However, LCJ staff provide inmates with informal training in the handling and cleaning of biohazard spills and on how to access the cleaning supplies.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should have their own policy, procedur e and staff and inm ate training program for this area of operation, including the specific areas of the jail where spill kits and biohazard supplies are kept.
h. LCJ shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
The facility continues to use universal cleaning chemicals for cleaning biohazard spills as well as a bleach solution.
RECOMMENDATIONS FOR THE NEXT VISIT:
1. LCJ supervisory staff should continue to en sure that staff and inm ates that clean biohazard spills follow the re commended instructions of the chemicals used f or the cleanup.

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i. LCJ shall inspect and replace as often as needed all frayed and cracked mattresses. LCJ sha ll destroy an y mattress that cannot be s anitized sufficiently to kill any pos sible bacteria. LCJ shall ensure that mattresses are properly sanitized between uses.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I did not detect any frayed or cracked mattress. There continues to be ample supplies of inmate mattresses in storage for replenishment purposes. Inmates are assigned to clean mattresses between uses. Staff and inmates continue to use sanitation chemicals in accordance with the sanitizing chemical instructions. LCJ staff continue to provide written directives to the trustees and to all inmates as to the proper method of cleaning and sanitizing of mattresses.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ supervisors should continue to train and instruct staff and inm ates that are responsible for sanitizin g mattresses on the proper use of the sanitizin g chemicals. Supervisory staff should continue to insp ect and review the m attresses sanitization process and ensure it is done correctly.
j. LCJ shall ensure adequate num bers of sta ff to perform housekeeping duties.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has two full-time and one part-time sanitation officers. These officers continue to provide cleaning materials to inmates and to some extent they also supervise trustee workers. However, inmate workers within the housing units continue to receive little, if any, instruction and supervision for their cleaning duties. I found that sanitation in the housing units has improved from my last tour, but not significantly. The bigger problem continues to be the general lack of supervision of inmates in the housing units. For example, I continue to observe only one floor officer trying to provide supervision to inmates in eight pods or two housing units in the new part of the jail, identical to previous finding. In the old part of the jail, I observed one officer trying to provide supervision of inmates in three to six living units (pods). It is unrealistic to expect that one officer can perform all the duties required of a floor officer and be able to perform them in a qualitative manner. I also observed that officers do not normally enter the actual inmate living areas, but rather patrol the outside of the dayrooms and the catwalks. If inmates are out of their cells, the officer does not go into the actual living area. I reviewed the Estimated Functional Bed Capacity Report 2010 authored by RJS and noted that the correctional officer force complement was inadequate. The report reflected a shortage of approximately 68

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correctional officers. I noted a similar inadequacy as I toured the housing units as described above. Additionally, during my previous tour, the Sheriff’s Office presented a comprehensive Staffing Analysis that reflected a shortage of 65 detention officers in order to be able to operate the LCJ in a safe and secure manner as well as to be able to achieve substantial compliance with various provisions of the SA. In my last tour, LCJ received approval from the Lake County Council to hire 12 additional correctional officers and another 18 new correctional officers are projected to be approved in the 2013 budget. These are steps in the right direction. There are simply an inadequate number of detention officers deployed into the housing units to properly supervise inmates and in particular, for supervising inmates that are performing housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to closely ex amine their correctional officer staffing levels and move towards provi ding direct inmate superv ision in the inm ate housing units in order to better supervise in mates and the housekeeping and sanitation program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
It is expected that LCJ officials continue to work with the Lake County Council in obtaining the proper staffing levels in the correctional officer ranks in order to be able to comply with the requirements of this paragraph of the SA.
2. Sanitary Laundry Procedures.
a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ has implemented appropriate procedures for the laundry to protect inmates from risk of exposure to communicable disease. As I have reported in my previous reports, this area of operation also has staffing implications. In order for LCJ to be able to maintain the laundry operation at this level and in order to be able to implement the proposed laundry schedule, as well as to be able to adequately distribute and pick-up laundry services to inmates in an orderly fashion, the laundry operation will have to expand its hours of operation as well as ensuring that there are ample numbers of detention officers in the housing units to assist in the laundry process. LCJ officials have implemented a twice weekly laundry exchange program for the female population, but not for the male inmates.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should ensure that there ar e adequate levels of detention officers available to be able to implement the revised laundry schedule.
b. LCJ shall e nsure that inmates are provided ad equate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards (e.g., at least twice per week), and that th e laundry exchange schedule provides consistent distribution and pickup servic e to all housing areas.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Based upon my review of purchasing records and observation, LCJ officials continue to maintain a substantial amount of inmate clothing, bedding and towels in order to satisfy this requirement of the SA. However, due to inadequate detention officer staffing levels, LCJ officials have not distributed or issued these items to inmates in accordance with the revised inmate laundry schedule, with the exception of the female population as previously noted above. Based upon my observations, review of documents and staff and inmate interviews, inmates are still not being provided with adequate quantities of clean clothing, underclothing and bedding. For example, laundry exchange still only occurs once per week instead of the required two exchanges per week for the male population. Inmates are only provided with one uniform, one sheet, one towel, one blanket, one mattress and a laundry bag. It appears that blankets continue to be exchanged at least once per month .
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It remains my recommendation that the in mate initial issue fo r bedding and hygiene consist of: one m attress; two bed sheets; two towels; and one blanket. The sheets and towels should be exchanged at least once per week, unless inm ates are only issued one sheet and one towel, then they should be exchanged twice per week. Records of services should be maintained.
2. LCJ should ensure that there are sufficient numbers of correctional officers available in order to implem ent the revised laundry sc hedule and to distribute adequate levels of clothing and bedding items to inmates.
c. LCJ shall train staff an d educate inmates regarding laundry sanitation policies.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
As I reported in my previous reports, it appears that a private vendor has continued to provide training to laundry staff. Security staff are provided training on the provisions of the SA as it relates to laundry issues. However, a system has not yet been developed and implemented for educating inmates regarding laundry sanitation policies. The Inmate Handbook could be used as one avenue for educating inmates on laundry sanitation policies; however, formal revisions to the Inmate Handbook are still pending. LCJ staff also reported that they intend to post laundry and sanitation expectations for inmates in the housing unit areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should include the provisions of the SA in their basi c and on-going staff training program so that security and la undry staff are fully aware as to their obligations regarding the facility sanitation policies.
2. The Inmate Handbook should be revised, finalized and include the expectations of inmates regarding laundry sanitation policies.
d. LCJ shall ensure that laundry delivery procedures protect inmates from exposu re to communicable diseases by preventing clean laundry from co ming into contact with dirty laundry or contaminated surfaces.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ staff have developed practices that protects inmates from exposure to communicable diseases. The laundry carts are still being cleaned and sanitized between uses. Staff and inmates are following the manufactures recommended instructions for the proper use of sanitizing chemicals. Facility staff have received training on the proper use of chemicals. Material Safety Data Sheets continue to be made available in various areas of the jail. I did not detect that clean laundry was coming into contact with dirty laundry or contaminated surfaces. LCJ staff have provided written instructions to inmates on the proper use of sanitizing chemicals.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to provide instructions and oversight to staff and inmates on the proper use of sanitizing chemicals and on cross-contam ination precautions.
2. LCJ staff should continue to m aintain Material Safety Data Sheets in strategic areas of the jail where chemical are used and maintained.
e. LCJ shall require in mates to pr ovide all cloth ing and linens for LCJ laundering and prohibit inmates from washing and drying laundry outside the formal procedures.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The Inmate Handbook has still not been revised to include provisions on prohibiting inmates from washing and drying laundry outside the formal procedures. During this tour, I did not observe inmates washing undergarments, clothing and towels in the sinks, showers or toilets. At least for the female population, LCJ staff continue to provide laundry exchange twice per week. However, the laundry exchange for the male population still only occurs once per week. LCJ staff have not fully implemented the revised laundry schedule due to the lack of staffing.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should contain a prov ision prohibiting inmates from washing and drying laundry outside the formal procedures.
2. Inmates should be issued sufficient quantitie s of clothing and towels to provide for proper hygiene and laundered as previously recommended in this report.
3. LCJ officials should implem ent the re vised laundry schedule and inmate issue provisions concomitant with an adequate facility staffing deployment plan.
3. Food Service.
a. LCJ shall ensure that food se rvice at LCJ is operated in a safe and h ygienic manner and that foods are served and maintained at safe temperatures, and adequate meals are provided.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
From my observations and interviews with staff and inmates, I found that adequate meals continue to be provided. Meals are prepared in a safe and hygienic manner. LCJ food service staff continue to make improvements in the area of food temperatures. Temperature readings of meals are taken and recorded. These temperatures are satisfactory. Food carts continue to be delivered to the housing units in a more prompt manner which has immensely helped in maintaining proper food temperatures at serving time. Once the carts are delivered to the housing units I observed that the meals were promptly provided to the inmates. However, this area will need to be monitored closely due to the typical shortage of staff in the housing units.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Supervisory staff should continue to m onitor food service operations and ensure that food service staff obtain and document food temperatures.

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2. Management staff and food service staff need to ensure that m eals continue to be delivered and provided prom ptly to inm ates so that problem s are not encountered with food temperatures.
b. LCJ shall ensure that all food se rvice staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I met with food service staff as well as conducting an inspection of the kitchen. Many improvements continue to be made in this area. For example, the dumpsters are still being cleaned on a weekly basis, food service equipment is maintained in good working order, among many other improvements. The dietician has continued to train staff as well as inmates on food service operations, the safe handling procedures and on appropriate sanitation. Records of these trainings are maintained. Material Safety Data Sheets continue to be made available in the kitchen.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to m aintain their tr aining records for food service staff and document all training provided, including food se rvice staff orientations. Copies of these staff training sessions should be provided to the LCJ Training Coordinator.
c. LCJ shall ensure that kitchen(s) are staffed with a sufficient number of appropriately supervised and trained personnel.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
The food service department continues to be staffed with nine food service workers. The food service operation continues to be supplemented with inmate workers. The number of staff assigned to the kitchen appears to be sufficient; however, any reduction on the current staffing levels could have negative implications on the food service operation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to m aintain at the very least, the current food service staff complement.
d. LCJ shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.

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OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During this tour, I found that dishes and utensils, food preparation and storage areas continue to be clean and sanitary. I also noted that the food service delivery carts and food tray storage carts continue to be appropriately cleaned and sanitized.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the daily, weekly and monthly sanitati on inspection program continues to be part of the food service system.
e. LCJ shall check and recor d, on a regular basis, the temperatures in the refrigerators, coolers, walk-inrefrigerators, the dishwasher water, and all other kitchen equipment with temp erature monitors to ensure proper maintenance of food service equipment.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ staff have developed and continue to maintain a system for checking and recording temperatures of the refrigerators, coolers, walk-in refrigerators and the dishwasher. LCJ staff are maintaining records of these checks.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
It is my recommendation that temperatures of all refrigerators, co olers, walk-in refrigerators and the dishwasher water continue to be checked and recorded. This will allow food ser vice staff to detect a temperature problem promptly so it can be corrected.
F. QUALITY IMPROVEMENT PROGRAM: Settlement Agreement Part III Section F.
1. LCJ shall develop and implement written quality management policies and proced ures to regularly assess, identify, and take all reas onable measures to as sure compliance with each of the provisions of this Agreement, as applicable.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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October 2012 Assessment: Basic policies and procedures are in draft form re: a quality improvement program. Little change has occurred since September 2011. October 2012 Recommendations for next 6 months:
1. Complete and implement the needed policies and procedures.
2. LCJ shall develop an d implement policies to address and correct d eficiencies that are uncovered during the course o f quality ma nagement activities, including monitoring corrective actions over time to ensure sustained resolution.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE October 2012 Assessment: The F.1 policy needs to be implemented in order to implement this provision of the SA. The QM/QI activities in the area of the mental health system remain very minimal. October 2012 Recommendations for next 6 months:
1. Complete and implement the needed policies and procedures.
3. LCJ shall institute a Quality I mprovement Committee and ensure th at such committee meets on a monthly basis and th at this committee includes representatives from medical, mental health, and custody staff.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE October 2012 Assessment: A QI committee has been established, which has met on a monthly basis since February 2012. Minutes are documented and shared. October 2012 Recommendations for next 6 months:
1. A mental health subcommittee m eeting should be established as part of this QI Committee
2. Begin to implement a more robust QI process re: the mental health services.

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4. Quality management programs related to me dical and mental hea lth care will utilize performance measurements to a ssess quality of care and timely access to care with quantitative and qualitative da ta analysis and trending o ver time an d specifically shall address: a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of suicide attempts, monitoring of inmates on suicide observations or precautions; d. the appropriateness of physical plan t facilities such as safe cells for management of at risk inmates, and follow-up and treatment for those who may have engaged in suicidal or self-harm activities; e. the appropriateness of treatment pla nning and treatment interventions for inmates in the mental health program; f. discharge planning for the ef fective management and c ontinuity of care for inmates leaving the system; and g. the quality of medical records and other documentation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
October 2012 Assessment: Some progress has occurred re: th ese SA provisions. Perform ance measures reportedly rem ain under developm ent in all areas. Utiliza tion of psychotropic medications was studied result ing formulary revisions resu lting in reduced costs and maintenance of treatment effectiveness.
An intake MH/SP QM report was developed a nd implemented to id entify compliance with screening completions, referrals, and care indicati ng that there gaps in assessm ent compliance. Changes were m ade to in staff deploym ent and oversight. The faci lity undergoes regular inspection to ensure cells are safe for inmates at high risk of self harm.
October 2012 Recommendations for next 6 months:
1. Complete and implement the ne eded policies and procedures as previously referenced.
G. PROTECTION FROM HARM: Settlement Agreement Part III Section G.
5. Use of Force by Staff.
a. LCJ shall develop and mainta in comprehensive and contemporary po licies and procedures surrounding the use of force and with par ticular emphasis regarding permissible and impermissible use of force.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
LCJ staff have developed and are m aintaining comprehensive and contem porary policies and procedures surrounding the use of force and em phasizes permissible and im permissible use of force. The revised Use of Force policy was signed by the Sheriff on September 14, 2011.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The finalized policy concerning the Use of Force should continue to be implemented.
b. LCJ shall address the following impermissible uses of force in its use of force policy and in the pre-service and in-service trainin g programs for correctional officers and supervisors: (1) use of force as an initial response to verbal insults or inmate threats;
(2) use of force as a response to in mates’ failure to fo llow instructions where there is no immediate threa t to the saf ety of the institution, inmates, or staff, unless LCJ has attemp ted a hier archy of nonphysical alternatives that are documented;
(3) use of force as punishment or retaliation;
(4) striking, hitting, or punching a restrained inmate;
(5) use of force against an inmate after the inmate has ceased to offer resistance and is under control;
(6) use of choke holds on an inmate; and
(7) use of unnecessary or excessive force.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The final Use of Force Policy and Procedure c ontains the provisions of paragraph b. and subparagraphs 1-7 of the SA.
The Use of Force pre-service and in -service training program on the Us e of Force Policy and Procedure has been initiated. L CJ has provided training on the Us e of Force p olicy to six instructors. Since m y last visit, ap proximately 95% of the correctional officers have received training on the Use of Force policy. Training on th e Use of Force policy is now part of the preservice and in-service staff training program . LCJ st aff, with the help o f their consultants, is in the process of developing an additio nal use of force training program for the super visors. LCJ staff are working diligently on im plementing the revised use of force program , but it will take some time to fully train and retrain all LCJ staff on this new program.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

LCJ officials need to continue to trai n correctional staff on the Use of Force

policy.

2.

LCJ staff need to develop and implement the supervisor use of training program.

c. LCJ shall d evelop and implement a polic y to ensure that staff adeq uately and promptly report all uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of For ce Policy and Procedure has been developed and finalized. The policy contains this provision of the SA. LCJ staff have commenced the process of providing training on the Use of Force policy to staff as noted prev iously above. Monitoring of the use of force reporting is conducted by the Sta ff Training Division and the Deput y Warden of Security. LCJ staff have developed a use of for ce tracking system which is still in its infancy stage, but shows signs of effectiveness. When fully implemented, the system should be capable of accounting for each and every use of force, both reported and unreported.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. LCJ officials should further refine their pr ocess of monitoring this requirement of the SA internally and ensure that all use of force information is entered into the use of force database and that it is accu rate and complete. There should be some method to verify that the use of force information is valid and verified.
2. LCJ staff should continue to qualitatively track, review and analyze use of force incidents for conformance with the SA.
3. LCJ staff should also deve lop a monthly tracking repor t for all use of force incidents in order to be able to conduct comparative reviews of the program.

d. LCJ shall ensure that use of force reports will:

(1) be written in specific terms in order to capture the details of the incident;

(2) contain an accurate account of th e events leading to the use of force incident;

(3) include a description of the weapon or instrument(s) of restrain t, if any, and the manner in which it was used;

(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;

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(5) state the nature and extent of injuries sustained both by the inmate and staff member;
(6) contain the date and time medical attention was actually provided;
(7) describe, in factual terms, the type and amount of force used and precise actions taken in a particular incident and avoid use of “boiler plate” descriptions for desc ribing force, such as, “inmate taken to the ground with the force that was necessary;” and
(8) note whether a use of force was videotaped. If the use of force is not videotaped, the reporting correctio nal officer and supervisor will provide an explanation as to why it was not videotaped.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policy and Procedure contains the elements of this provision of the SA including sub-paragraphs d. 1- 8. The revised Use of Force Policy and Procedure has been approved and signed and implementation has commenced.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented. LCJ staff should be conducti ng qualitative reviews of use of force

reports to ensure conform ance with th e SA a nd the Use of Force Policy and

Procedure.

2. I would als o recommend that a n ew use of force report f orm be developed and

implemented that includes all the elements of this provisions of the SA. A draf t

report is reportedly under review by the IA Captain of which I will review in m y

next reporting period.

e. LCJ shall require prompt admin istrative review of use of force reports. Such reviews shall include case-by-case review of individual incidents of use of force as well as more systemic r eview in order to identify patterns of incidents. LCJ shall incorporate such information into quality management practices and take necessary corrective action.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:

The revised Use of Force Policy an d Procedure contains the provisions of this paragraph of the SA. LCJ staff have commenced the process of training staff on the revised Use of Force policy. As reported earlier in this report, most of the correctional officers have already received training on the new Use of Force policy, but a separate use of force training com ponent is being developed for supervisors that also needs to be fully implemented.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented and continue to train security staff and supervisors on it as part of

the pre-service and in-service training program.

2. It was my recommendation in my previous report that all use of force incidents

continue to be reviewed by the Deputy Warden of Security and the W arden.

However, I would also be receptive to the idea of LCJ having a m ulti-disciplinary

team reviewing use of force incidents.

3. During my next review I will be review ing use of force reports and the review

process of use of force incidents.

f. LCJ shall ensure that Qualified Medi cal Staff reques t that inma tes sign arelease of medical records for the limited pur pose of adminis trative and investigative review o f any incident in volving an inmate in jury. Qualified Medical Staff will docu ment the re quest and the inmate’ s response. LCJ will ensure that inma tes receive adequate medica l care regardless of whether they consent to release their medical records.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

This provision of the SA is addressed in the re vised Use of Force Policy and Procedure. LCJ staff and their consultants are working with Dr. Ron Shansky on ensuring that these requirements of the SA are m et and are also add ressed in medical policy and procedure. LCJ s taff reported that this task remains under development.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. It is recom mended that the m edical policies and procedures be developed and finalized and include these prov isions of the SA and that both security and medical staff start receiving training on them.

g. LCJ shall ensure that manageme nt review of use of fo rce reports and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical docume ntation of inmate injuries as reported by Qualified Medical Staff, includ ing documentation surrounding the initial

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medical encounter, an anatomical dr awing that depicts the areas of sustained injury, and information regarding any further medical care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the rev ised Use of Force Policies and Procedures. RJS consulting staff are wor king with th e medical staff in ensuring that the medical policies and procedures address these provi sions of the SA as well. LCJ staff reported that this task remains under development.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ Staff s hould continue with the im plementation the revised Use of Force Policy and Procedure.
2. The medical policies and procedures s hould be developed and im plemented and should contain the provisions of this paragraph of the SA.
h. LCJ shall establish criteria that trigger referral for use of force investigations, including but not limited to, injuries that are extensiv e or serious; injuries involving fractures or h ead trauma; injuries of a suspicious nature (including black eyes, broken teeth, injuries to th e genitals, etc.); injurie s that requ ire treatment at outside hospitals; and reports of events by staff and inmates that are inconsistent.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. As addressed previously in this repo rt, considerable staff training has already been conducted regarding this provision paragraph of the SA. However, all staff need to be trained on it as part of the pre-service and annual in-ser vice staff training program as well as developing and implementing the supervisor use of force tr aining. It does not app ear that a triggering referral for use of force investigations has been developed and implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to train all correctional staff on the revised Use of Force Policy and Procedure.
2. During the course of use of force revi ews management staff should start to qualitatively assess the triggering criteria for use of force investigations and make the necessary referral to IA.

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i. LCJ shall d evelop and implement a system to track a ll incidents of use of force that, at a minimum, includes the following information:
(1) a tracking number; (2) the inmate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA ha ve been incorporated into the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved, signed and partially im plemented. The system to track all incidents of use of for ce has been developed and is in the initial stage of i mplementation. RJS Consultants continue to provide guidance in this critical area of the use of force program.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The revised Use of Force Policy and Procedure should continue to be

implemented.

2.

The system for tracking all incidents of use of force should be continue to be

implemented and adjusted as needed.

j. LCJ shall ensure that as part of a us e of force incident package, security supervisors shall ensure that photographs are taken of any and all reported injuries sustained by inmates and staf f promptly following a use of force incident. T he photographs will beco me evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT: These provisions of this paragraph of the SA a re contained in revised Use of Force Policy and Procedure. The revis ed Use of Force Policy and Procedure has been approved and signed and

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partially implemented. There has been considerable training provided on these provisions to LCJ staff. LCJ staff are in the p rocess of deve loping and implem enting a use of force training program for supervisors who play a critical role in the use of force program. Video recordings of use of force incidents are maintained by the Deputy Warden. During the tour I review ed several use of force video recording. Supe rvisors are required to obtain photographs of reported injuries sustained by inmates during a use of force incident.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy should continue to be implemented in order to be able to fully evaluate compliance with the SA.
2. During the next tour, I will be revi ewing additional vide o recordings and photographs taken following use of force incidents.
3. LCJ staff should consider developing separate “use of force package” for each use of force incident that co ntains all documents and evidence for every use of force incident.

k. LCJ shall establish an “early warning system” that will document and track correctional officers who regularly employ force on inmates and any complaints related to the excessiv e use of force, in order to alert LCJ administration to any potentia l need for retraining, problematic policies, or supervision lapses. Appropriate LCJ leadership, supervisors, and investigative staff shall have acces s to this in formation and monitor the occurrences.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT: An early warning system is addressed in the revised Use of Force Policies and Procedures. The revised Use of Force policy and procedure has been approved and signed and implemented. It is too early to ev aluate the o verall requirements of these provis ions of this paragraph of the SA because the overall sys tem is not yet develop ed and im plemented. Currently, there is an inform al process in place whereb y the Deputy W arden reviews and monitors use of force reports.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented.

2. Concomitant with the implem entation of the Use of Force Policy and Procedure,

LCJ staff s hould start deve loping and im plementing the early warning system

described in the revised Use of Force Policy and Procedure. RJS Consultants can

assist LCJ in this endeavor. The process remains informal at this time.

l. LCJ shall ensure that a superviso r is present during all planned uses of force.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

This provision is addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approve d and signed and partially im plemented. It appears that a supervisor is deployed to planned us es of force events. It should be noted that I reviewed a use of force incide nt that occurred on Septem ber 5, 2012 involving th e refusal of several inmates to lock down that was not han dled very well in la rge part due to security staff shortages. The incident occurred in Y-Control at approximately 4:45 pm on September 5, 2012; however, due to staff shortages at the facility and the lack of floor officer to intervene, the SORT team did not respond until approximately 5:55 on the same day upon th e second shift reporting for work. The incident involved the use of pepper balls to finally ge t the inmates into their cells. There was certainly too much lag time in getting the incident under control and could have easily escalated beyond what it did and cou ld have resulted in a more serious incident. Additionally, if there had been sufficient staff to prom ptly respond to the initial inci dent, it m ay not have escalated to a use of force incident.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. The revised Use of Force Policy and

Procedure should continue to be

implemented.

2. During the next tour I will be reviewing planned uses of force f or compliance

with this provision of the SA.

m. Where there is eviden ce of staff mis conduct related to inappropriate or unnecessary force against inmates, LCJ shall initiate appropriate personnel actions and systemic remedies, as appropriate. LCJ shall discipline appropriately any correctional officer found to have:

(1) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or oth er staff member for reporting the
use of excessive force; or (4) interfered or failed to coopera te with an internal investigation
regarding use of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policy an d Procedure contains the provisions of this paragraph of the SA. The revised Use of Force Policies and Procedures have been approved, signed and partially implemented. LCJ staff reported that there was one referral made to the IA Unit re garding the inappropriate use of force during this reporting period. However, I was not able to obtain a copy of the investigation because IA staff were unavailable during the inspection.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the revised Use of Force Policy and Procedure continue to be implemented so that full compliance can be evaluated with respect to discipline of staff that have used inappropriate or unnecessary force against inmates.
2. During the next site visit I will be review ing any IA investigations regarding staff use of force violations as well as personnel records.
n. LCJ shall develop and implement accountability policies and procedures for the effective and acc urate maintenance, inventory and assignment of chemical and other security equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedures address incapacitating agents, electronic control devices and the us e of the restrain t chair. Th e procedure for the m aintenance, inventory and assignment for the electronic control device is addressed in the use of force policy. However, the policy does not contain those contro ls for restraint equipm ent such as handcuffs and leg irons. However, LCJ continues to m aintain other po licies and procedures governing all security equipment and have been cross-ref erenced with the Use of Force Policy and Procedure and contain the specific provisions of this paragraph of the SA. During this tour and in my previous tour I reviewed use of force incidents. I noted in both of my inspections that in many instances where the Taser was deployed, it was generally used on mentally ill inmates or in the intake area. In my previous report I noted that that the tase r was not always deployed in a safe manner. For example, the target area should not be in chest area, but some inm ates were tased in that area of the body and in som e instances, while not necessar ily intended, were tased to the neck or face area. I further noted that some inmates were tased multiple times with both the electronic prongs and in the drive stun mode with the Taser in conjunction with physical force and restraint operations. During this inspection I reviewed 2 videos involving male staff that were involved in handling a female mentally ill inmate th at was naked and rem oved from her cell while m ale inmates cleaned her cell. I believe L CJ staff should carefully review the use of force involving mentally ill inmates and seek better methods for handling them.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. RJS staff should continue working with LC J staff in addressing the proper use of the Taser and its application on mentally ill inmates as well as other types of force used on the mentally ill. During th e next tour I will be re viewing use of force reports and also assessing efforts LCJ st aff have m ade on t he proper use of the Taser.

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o. Use of Force Training:

(1) LCJ shall develop an effective and comprehensive training program in the appropriate use of force.

(2) LCJ shall ensure that correctiona l officers receive adequate training in LCJ’s use of force policies and procedures.
(3) LCJ shall ensure that correctiona l officers receive adequate training in use of force and defensive tactics.

(4) LCJ shall ensure that correctio nal officers receive p re-service and in-service training on reporting us e of force and completing use of force reports.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The staff training provisions for the requirem ents of this paragraph of the SA have been

developed and the im plementation process has co mmenced. Six use of force instructors have

been identified and have received an 80 hour tr aining course on the use of force. A 40 hour

training course on the use of force for offi

cers and supervisors has been developed.

Approximately 95% of the correct ional officers have been trai ned. A separate use of force

training program is being developed for the superv isors. In addition to the above use of force

training, there is a 4 hour in-service training component on the use of force.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. LCJ should continue to provide staff training to all officers and supervisors on the use of force in accordance with their training schedule.

p. LCJ shall ensure that inmates may report allegations of the use of excessive force orally to any LCJ staff member , who shall reduce such reports to writing.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. The revised Use of Force Policies and Proce dures have been approved signed and partially implemented. LCJ officials should continue to monitor this provision during the course of use of force reviews. Also, this reporting provisi on should be addressed in the Inm ate Handbook s o that inmates are fully aware of reporting avenue.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. LCJ staff s hould revise the Inm ate Handbook and insert language that allows inmates to report allegations of the use of excessive force orally to any LCJ staff member. LCJ staf f reported that this provision is contained in the Inm ate Handbook, but it does not appear to be specific to the use of force.
q. LCJ shall ensure that Qualified M edical Staff question, outside the he aring of other in mates or correctional officers if ap propriate, each inmate who reports for medical care with an injury, regar ding the cause of the injury. If, in the course of the inmate’s medical encounter, a health care provider suspects staff-on-inmate abuse, that health care provider shall immediately:
(1) take all appropriate steps to pr eserve evidence of the injury (e.g. , photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator;
(3) adequately document the matter in the inmate’s medical record; and
(4) complete an incident report.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragr aph of the SA are add ressed in the revised Use of F orce Policy and Procedure. The rev ised Use of Force Poli cy and Procedures has been approved signed and partially implemented. LCJ staff continue to wo rk with the m edical staff to ens ure that the medical policies and procedures also contain the provisions of this paragraph of the SA.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. These provisions should also be addressed in the medical policies and procedures.
r. LCJ shall develop, assign, and train a team of specialized use of force investigators that will be charged with conducting inves tigations of use of force incidents. These use of force in vestigators shall receive at the outset of their assignment, specialized trai ning in investigating use of force incidents and allegations.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the rev ised Use of Force Policies and Procedures. The revised Use o f Force Policies and Procedures have been approved, signed and partially implemented. The Sheriff has desi gnated two Lake County Police investigators to serve as the specialized use of force investigators as requ ired by this paragraph of the SA. During my previous tour I interviewed the Chief Investigator and noted that he has substantial experience in both crim inal and adm inistrative investigations and had served as Deput y Commander of Investigations for the Lake Coun ty Policy Department for approximately 6 1/ 2 years in addition to other law enforcement experience. The s econd investigator also possesses substantial investigative experience. LCJ staff reported that they are in the process of developing an investigative guideline manual for use by the specialized use of force investigators.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. It is further recomm ended that LCJ officials develop and im plement their investigative guideline manual for the use of force investigative process.
3. I also reco mmend that the specialized use of force inv estigators receive for mal training on the revised Use of Force pol icy to f urther assist the m in their investigative duties. This can be accomplished in a 2 to 3 hour training session.
s. LCJ shall ensure that incident repor ts, use of force reports and inmate grievances are screened for alleg ations of staff miscon duct and, if the incident or allegation meets established criteria, tha t it is ref erred for investigation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures address the provisions of this paragraph of the SA. The revised use of Force Po licies and Procedures have been approved, signed and partially implemented. Supervisory staff re portedly screen inmate grievances for allegations of abuse as well as incident reports and use of force reports.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented. 2. During the next tour I will be reviewing specific instances regarding allegations of
staff misconduct for conformance with this provision of the SA.

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FIFTH COMPLIANCE REPORT LAKE COUNTY JAIL AUGUST 2013

A. MEDICAL CARE: Settlement Agreement Section III Part A.

1. LCJ shall provide adequate services to address the serious medical and mental health needs of all inmates.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

Leadership for the medical program at Lake County Jail has been in place since January of 2012 and in general is performing well. T he organization has improved its ability to measure performance against the Agreed Order but this has been challenging due to the difficulty in obtaining data from the current electronic record. The program was able to provide data on several items requested on an ongoing basis.

• The length of time from intake screening to provider assessment by acuity status. o Because the program has just completed implementation of intake screening utilizing a priority status system the data provided is not yet accurate. T he program provided data reporting the percent of patients screened by priority. As of January of 2013 only 34 Priority 1 inmates were reported as receiving provider evaluation based on intake referrals. This is significantly below expectations given that 1135 inmates were incarcerated. O n chart review it was clear that patients are not being given accurate priority assignment. In February 97 inmates were reported as evaluated which is also below expectation. The program also reports the number evaluated within 24 hour s and those greater than 24 hours. For January of the 34 people evaluated, 31 were reported as evaluated within 24 hours for 91% compliance. F or February 91.75% compliance was reported. However, if the priority status is not being assigned correctly, then the numbers reported are not meaningful. So the way the report is structured is acceptable, but the results are not meaningful because the priority system of intake screening needs further modification and training.
• Percent of incarcerated detainees who receive intake screening. o The program reported that in January of 2013 there were 1135 admissions and 1037 (91%) intake screenings. In February 2013 there were 906 ( 83%) intake screenings for 1085 a dmissions. T hese are not good numbers and require explanation. The program should separate persons who are pre-booked from booked so that they are not counting in the intake numbers people who after a prebooking screening are immediately released or sent to a hospital.
• Percent of incarcerated detainees who receive tuberculosis screening. o The program reported in their Quality Improvement Committee tuberculosis skin testing data which does not compute. They report data in a table which indicates that for January 2013, 1003 Mantoux skin tests were applied, 491 tests were read, and 451 inmates were released apparently before the test could be read. 491 and

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451 does not add up to 1003 tests applied. This may imply that 61 inmates did not have their test read. D id half of the inmates leave before 72 h ours of incarceration? As well, the program reported 1135 admissions for January but only reported 1003 M antoux skin tests applied which is only 88% on i nmates screened for tuberculosis. This number should be 100%. • Number of health care slips picked up daily and triaged within 24 hours. o The program reported that 735 he alth requests slips were placed in January or approximately 24 a day. For February they report 713 requests placed or approximately 25 r equests a day. T hey are reporting that 100 % were triaged within 24 hours. • Number and percent of symptomatic complaints on health care slips which have a faceto-face evaluation within 72 hours. o For face to face evaluation, the program reported a study from mid-February to mid-March. Because of the dates chosen, the numbers could not be compared to their monthly reported data. In this sample, they report that of the 799 requests only 303 ( 37%) involved a symptom. Of the 303 s ymptomatic complaints reported only 177 r eceived a face-to-face evaluation. T his was 58% of symptomatic complaints but only 22% of total complaints. o The program also reports 65 i nmates refused evaluation which is 21% of symptomatic complaints. This is a high number indicating a potential problem. • Average time from physician order to administration of medication for prescription medication. o The program reported that 98.93% of inmates receive their first dose of medication after a provider order within 1 day. This is tracked utilizing ordering data and data from the medication administration software. This is an acceptable number. • A no show report indicating the number of specialty, sick call, and provider appointments who showed up and were seen as well as those who don’t show and the reason for no show. This should include percentages. o The program reported data in a study of a portion of scheduled appointments, specifically a no-show study of 14 da y history and physical examinations. This was done for February of 2013. Of 930 appointments, only 130 (13.9%) were completed. The study indicated that 65% of appointments didn’t occur because the inmate was no l onger in the facility. The released inmates should not be included in the study. If this is done, there would be 326 a ppointments for February of which 130 ( 40%) took place. T his is a very low number. 17% of inmates were said to refuse appointments which is also a very high number of refusals. Further investigation into the cause of refusals should be undertaken. o A study of specialty provider appointments for February 2013 was performed. Of 15 appointments, 10 were seen. 2 patients were released.
These form a good basis for quality metrics. However, not all quality improvement metrics have been developed. I would suggest that the group work with Dr. Shansky in developing these. I would include quality of primary care medical notes as one of these audits.

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RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Improve metrics outlined above as part of a Continuous Quality Improvement Program and continue to improve data collection for the existing metrics.
2. LCJ shall develop and implement medical care policies, procedures, and practices to address and guide all medical care and services at LCJ, including, but not limited to the following:
(1) access to medical care; (2) continuity of medication; (3) infection control; , (4) medication administration; (5) intoxication and detoxification; (6) documentation and record-keeping; (7) disease prevention; (8) medical triage and physician review; (9) intake screening; (10) infection control; (11) comprehensive health assessments; (12) mental health; (13) women's health; (14) quality management; and (15) emergent response.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
Policies and procedures need to provide concise and simple directions for staff regarding expectations. T oo much effort is now being expended on r ationales, background, theoretical, and other unnecessary information.
The team needs to focus on the 15 policies required in the Agreement. The policies need to be: • Simplified • Written for line staff • Focused on the items in the Agreed Order • Written as combined policy and procedure (when a lengthy procedure subject to change is part of the procedure, include it as an appendix rather than incorporate it into the document) • Addresses all areas of concern in monitoring
Writing policies needs to be followed by staff training and implementation. In addition, there are several areas including medication administration, intake and infirmary or special needs housing which should result in combined custody/medical inter-agency policies which describe responsibilities of medical and custody staff. I recommend that medication administration and

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access to care (sick call) be topics for combined custody and medical inter-agency procedures. The custody procedure should become part of the post orders for officers.

For policies that are written, they would be improved by simplification and by providing clear direction to line staff who will use them. They are still attempts at academic presentation rather than simple directions to line staff, giving guidance in key areas of service.

Under this agreement policies must be developed in multiples areas of service. The policies sent to me did not include policies in the following areas:
• Medical triage and physician review • Intake screening • Comprehensive health assessments- chronic illness management • Emergency response • Disease prevention

Other policies were provided but many either need revisions or should be re-written. These include:
• The access to care policy is inadequate as it does not address access to the gamut of heath services available to inmates. As well, it does not address access to care through health requests.
• Infection control needs some revisions. • Intoxification and detoxification need to be re-written.

The following are comments on individual policies. • The influenza procedure in the Infection Control policy recommends isolation of suspicious cases but does not indicate where patients are to be isolated. Isolation implies negative pressure housing but there are no negative pressure rooms in the jail. The same policy recommends isolation for all detainees in contact with the affected individual. Where are these detainees to be isolated? If the individuals are to be housed alone in single cells, this may be appropriate for influenza but would not be appropriate for diseases such as tuberculosis. • In the influenza procedure how often are vital signs done for suspicious cases? • In the tuberculosis policy, it recommends isolation of persons suspicious for active tuberculosis until they are cleared. Since there are no negative pressure rooms at the jail, where are these individual to be housed? These patients should be immediately masked and sent directly to a hospital for evaluation. They should not be housed at the jail. There are several such references like this in the policy. • The policy recommends isolation for all persons with a positive Mantoux skin test until they receive a chest film. Where are these individuals to be isolated? Prompt x-rays are considered sufficient and Mantoux skin test positivity does not require isolation. • The tuberculosis policy states that a Mantoux skin test of 5 mm is positive if they are infected with HIV or have an x-ray with abnormal findings. Does this mean that all persons with a 5 mm skin test have an x-ray and HIV test? This should be clarified. • The policy recommends contact investigation only for suspected or confirmed pleural cavitary disease or positive AFB. Contact investigation should be initiated for all active tuberculosis cases.

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• The contact investigation procedure recommends that only contacts with the greatest degree of exposure should have skin testing. All contacts should be skin tested.
• The sexually transmitted disease policy under the HIV section, #1 states that “everyone will have one screen test for HIV in their life who is sexually active”. This is not clear. Does this mean that everyone is tested for HIV?
• The STD procedure states that “Positive HIV and RPR tests will be confirmed by specific tests approved by the Medical Director on a case specific basis”. This is inappropriate. All positive syphilis and HIV tests should automatically result in confirmatory testing. There should be no need for Medical Director approval. Most laboratories automatically reflex positive screening tests with a confirmatory test so this statement is probably unnecessary to state.
• The STD procedures recommend specific drugs for treatment. Because these drugs change frequently due to antibiotic resistance patterns, it is best to refer to the CDC latest version of STD treatment guidelines instead of trying to give guidance on specific treatment.
• The policy on medication administration training and the policy on pharmaceutical operations states that Corrections Officers administer or deliver medication. Correctional Officers should not administer or deliver medication.
• The pharmaceutical operations policy permits corrections officers access to stored controlled substances. This is inappropriate.
• The continuity of care policy recommends that a SMP reviews discharge instructions after hospitalization, ER visit or off-site consultation. The timeliness is not stated. This should be promptly upon return.
• The continuity of care policy item #4 Periodic Health Assessments doesn’t give any direction about what periodic health assessments will be done. It also does not specify which protocols “promulgated by nationally recognized organizations” will be utilized.
• The policy Care of the Pregnant Female states that if an inmate believes she is pregnant the test is done at the 14 day assessment. The test should be done as soon as the inmate states that she might be pregnant.
• The Care of the Pregnant Female policy does not state the laboratory tests which should be done. It also states the HIV testing is offered when indicated. HIV testing is indicated for all pregnant females. Other laboratory testing should follow American College of Obstetrics and Gynecology (ACOG) guidelines.
• Prenatal care should follow ACOG standards. • The Care of the Pregnant Female policy does not specify who provides prenatal care to
the pregnant female. Optimally, this is an obstetrician. If this can not be arranged a Family Practitioner who is trained in prenatal care can be a substitute. Prenatal care should not be provided by clinicians who have not had training and experience in prenatal care. • The Inmates with Alcohol and Other Drug Problems states that Correctional Officers conduct intake screening. This is inappropriate. • In general the Alcohol Detoxification procedure should be re-written for clarity and appropriateness. It gives various recommendations which at times seem contradictory (e.g. admission to a hospital for a CIWA of 24 in one section and a CIWA of 15 in another section), confusing or inappropriate directions regarding medication use (use of midazolam for seizures and Phenobarbital for detoxification), unclear directions on how

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to use the CIWA scale, and poor directions regarding where patients identified at intake screening in need of detoxification are to be housed. This procedure should be simplified and clarified. Other comments on this policy are listed below.
o The Alcohol Detoxification procedure states that if a patient is unable to walk or almost unconscious the patient should be transferred to a hospital. However, any sign of delirium tremens should prompt evaluation by a physician and transfer to a hospital if a physician is not present. The same procedure states that if an arrestee is uncooperative or unable to be evaluated, the arrestee should be returned to custody and brought for later evaluation. Being uncooperative is characteristic of persons in delirium tremens. Therefore this is poor and potentially dangerous advice.
o Item B in this policy is not clear. It appears to be saying that persons who are detoxifying or withdrawing from alcohol and are uncooperative are managed by custody with vitals every 4-8 hours until cooperative. These individuals should be under medical supervision.
o In the Alcohol Detoxification procedure, Phenobarbital is recommended for use in withdrawal. Phenobarbital is not recommended for alcohol withdrawal.
o The Alcohol Detoxification procedure, item H recommends lorazepam for a CIWA score above 15, but at this score, the patient should probably be hospitalized.
o The medication recommendations in the Alcohol Detoxification procedure are confusing. Use of lorazepam, tegretol and Phenobarbital are all recommended and it is not clear when these are to be used. Phenobarbital is not recommended in withdrawal syndromes.
o How the CIWA scale is to be used is not clear. This scale can be used to determine appropriate housing for the inmate, the status of the withdrawal, and to stage medication dosing. In this procedure it is unclear how to use this instrument.
o The Alcohol Detoxification procedure recommends hospitalization for a CIWA score above 24. Scores above 15 generally require hospitalization or at a minimum, immediate physician evaluation.
o The Alcohol Detoxification procedure states that midazolam (Versed) is the drug of choice for seizures at Lake County Jail. This is dangerous as this medication is not even recommended for routine seizure use and should only be used in a hospital or outpatient surgery center. There is a black box warning for this drug as the risk of respiratory depression or respiratory arrest is present. This drug is recommended for intractable status epilepticus not for withdrawal or typical seizures. It must be used with extreme caution in noncritical care settings.
• The benzodiazepine detoxification /withdrawal procedure needs to be re-written. o Item A under the subcategory Dosages in this policy is not understandable. Does this mean that all patients withdrawing from benzodiazepines are treated with Phenobarbital? Phenobarbital is not recommended for use in benzodiazepine withdrawal. o The reason for giving a loading dose of Carbamazepine does not appear to have a clinical basis and it is not clear if this drug is to be used on all patients experiencing benzodiazepine withdrawal.

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o The medication recommendations in this procedure need to be reviewed for clinical appropriateness.
• For the opiate withdrawal procedure it is not clear where persons with opiate withdrawal are to be housed.
• One major cause of death in patients experiencing opiate withdrawal is inability to consume liquids or food due to vomiting. This should be addressed in the procedure.
• In the Withdrawal from Stimulants procedure, beta-blockers are recommended for tachycardia. This should be reviewed for clinical appropriateness.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1. Develop key policies relevant to this agreement and listed in Part A, item 2 of the Agreement.
2. Ensure leadership involvement in policy development. 3. Follow up policy development with training and implementation. 4. In key areas, have interagency policies which coordinate custody and medical
responsibility for certain processes: e.g., medication administration, intake procedures, access to care, and special housing care or infirmary care.

3. Intake Screening and Health Assessments.

a. LCJ shall develop and implement policies and procedures to ensure that adequate medical and mental health intake screenings and health assessments are provided to all inmates within 14 days.

b. LCJ shall ensure that, upon admission to LCJ, Qualified Medical Staff utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, and seek the inmate's cooperation to provide information, regarding:

(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 illness and treatment, including medication and
hospitalization. Inmates who screen positively for any of these items shall be referred for timely medical evaluation, as appropriate.

c. LCJ shall ensure that the comprehensive assessment performed for each inmate within 14 day s of his or her arrival at LCJ shall include a c omplete medical history, physical examination, mental health history, and current mental status examination. The physical examination shall be conducted by Qualified Medical Staff. Records documenting the assessment and results shall become

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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 Medical Staff shall review prior records and update tests and examinations as needed.
d. LCJ shall ensure that Qualified Medical Staff 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.
e. LCJ shall implement a medication continuity system so that incoming inmates' medication for serious medical needs can be obtained in a t imely manner, as medically appropriate when medically necessary. Within 24 hours of an inmate's arrival at LCJ, or sooner if medically necessary, Qualified Medical Staff shall decide whether to continue the same or comparable medication for serious medical needs. If the inmate's reported medication is discontinued or changed, a Q ualified Medical Professional shall evaluate the inmate face-toface as soon as medically appropriate and document the reason for the change.
f. LCJ shall ensure that 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 Qualified Mental Health Professional. Staff will constantly observe such inmates until they are seen by a Qualified Mental Health Professional. Incoming inmates reporting these conditions will be housed in safe conditions unless and until a Mental Health Professional clears them for housing in a medical unit, segregation, or with the general population.
g. LCJ shall ensure that all inmates at risk for, or demonstrating signs and symptoms of drug and alcohol withdrawal are timely identified. LCJ shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.
h. LCJ shall incorporate the intake health screening information into the inmate's medical record in a timely manner.
i. LCJ shall ensure that correctional officers supervising newly arrived inmates 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 the intake health screening by Qualified Medical Staff.
OVERALL COMPLIANCE RATING: Partial Compliance

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ASSESSMENT:
3.a.
The policy on reception screening is still incomplete. The procedure should include acuity rankings. I discussed the acuity ranking system with medical leadership. The process of assigning acuity and follow up with a primary care provider should be included in the procedure. This should include timeframes for assessments. Also, the detoxification protocol should be revised and include criteria for who should be included in the protocol. There should be direct provider involvement in starting a detoxification protocol; some of this may need to be telephonic. TB screening should be included in the intake procedures.
Currently, CHI has provided for nurse intake screening 24/7; this is working well and staff are performing well. Construction of an intake medical screening area has been completed and is adequate with a minor exception. The screening area is built with concrete and sound reverberates such that all evaluations can be heard. Some type of soundproofing needs to be added.
3 b. (1-7)
The existing medical intake form in electronic format is adequate for purposes of screening.
3 c.
Based on chart reviews, people with chronic medical illness are not timely evaluated. The program has established acuity based screening to include 4 priority rankings. These priority rankings do not seem to be useful guidance to staff because many charts reviewed included patients who should have been seen promptly but were given low priority ranking and were seen later.
Based on the intake screening data and on chart reviews, the priority rankings do not appear to be effectively used in identification of the acuity of the chronic illness. Because nurses perform this function, the procedure should be written so that nurses understand how to make these assignments. As well, the intake nurses should be trained on how to perform this evaluation.
In addition, the priority rankings start with a moderate disease classification. It is not clear how patients with severe disease or more acute problems are addressed. This needs to be included in the priority designations.
As a result of ineffective priority assignments by nursing, providers are not timely evaluating patients with serious chronic illness. As well, the quality of the evaluation needs to improve. The first assessment evaluation should be a focused history and physical examination concentrating on the patient’s chronic illnesses. There were multiple examples of initial assessments in which providers took no history except to state the patient’s disease.

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3 d.
Nurses are appropriately and reasonably obtaining medication history from incoming detainees. The nursing staff in intake do take adequate history of prior medication use. As well, they attempt to contact local pharmacies to establish the accurate existing prescriptions for incoming inmates who are on medication. This was verified on chart reviews.
3 e.
For a sample of records reviewed, patients coming into intake on medication received their first dose at the facility within a day. This occurs apparently via a telephone order. However, there is no documentation that a telephone order was taken and providers often do not sign these orders. Unsigned orders can be listed in a report. If such reports were used and managed, these unsigned orders could be substantially reduced. This must be done, because in CorrectTek, a nurse can write an order under a provider’s name. If not signed, it appears as if the provider is writing a prescription when, in effect, it is a nurse.
The program provided data that 98.9% of patients receive their first dose of medication within a day. I reviewed the data used for this and it appears appropriate.
3 f.
Refer to Dr. Metzner’s report.
3 g.
The standardized detoxification procedure is not yet complete. The program continues to promote use of Phenobarbital as the primary drug used for alcohol withdrawal. This is not the standard of care. Phenbarbital is acceptable for refractory withdrawal when a benzodiazepine is ineffective. The draft policy on intoxication and detoxification was reviewed with leadership.
LCJ’s detoxification procedure should identify a place to house persons undergoing detoxification. There is no data on the numbers of persons who are in need of detoxification. However, these individuals are best housed in a single location because of the number of nursing interventions they will need over the first few days of incarceration. The LCJ compliance progress report indicated that detoxification patients will be housed on the 4th floor after mental health patients move to a different location. This was not yet in place at the time of our visit.
3 h.
The intake screening information is electronically incorporated into the medical record and all records were accessible to me upon inspection. There was no problem locating intake screening records.

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3 i.
The intake process is not described in a standardized procedure. Due to the chaotic nature of this process, I could not verify the role of the correctional officer in this process. The responsibilities of the officers, including the roles of observation of inmates by officers prior to medical screening, should be codified in a standardized interagency procedure.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The system should improve the acuity ranking system so that those with serious medical problems are timely seen after intake screening. Providers should prioritize those detainees with serious medical conditions. This should be codified in a standardized policy and procedure.
2. The intake screening booths should have some sound baffling to ensure sound privacy in screening evaluations.
3. Standardized alcohol and opiate withdrawal procedures should be revised and synchronized with orders in the electronic record. These procedures should be approved by the Medical Director and should be consistent with standardized treatment of withdrawal syndromes. Existing procedures must address how to use the CIWA scale to determine who should be sent to a hospital, how to start or continue medication, where patients in detoxification should be housed, and how follow up of detoxification is to occur.
4. Re-evaluate medication used in the withdrawal procedures. 5. CHI should work with the Sheriff to have an Interagency Intake policy and procedure
which states the responsibilities of officers and medical staff in intake. 6. Verbal orders must be signed by providers and signature must be clear in the record. 7. Develop a procedure for alcohol intoxication. 8. Include in the detoxification procedure opiate withdrawal and how it will be handled.

4. Acute care.

a. LCJ shall provide adequate and timely acute care for inmates with serious and life-threatening conditions, and ensure that such care adequately addresses the serious medical needs of inmates. Adequate care will include timely medical appointments and follow-up medical treatment.

OVERALL COMPLIANCE RATING: Partial Compliance

ASSESSMENT:

4 a.

The policy on e mergency medical response and admission to hospitals is not yet completed. There should be a procedure for emergencies which require hospitalization and how a detainee would be evaluated and sent to a hospital. As well, there should be a procedure for onsite urgent care evaluations.

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A comprehensive urgent care log is maintained based on notes extracted from CorrecTek. This note extraction takes a considerable amount of work. I was provided logs for March and April of 2013. This log contains data from the urgent care template present in CorrecTek. There were 195 urgent evaluations in March 2013. This data is now tracked on a monthly basis. The time of urgent care evaluations are also tracked.
The data for this log comes from a template within the electronic record. T he template, according to the LCJ Compliance Report includes a disposition or management section. However, this information is not consistently completed. F or one patient seen on 4/ 7/13, the patient complained of repeated vomiting and diarrhea. This patient had a pulse of 105 and a blood pressure of 82/44 which is very low. B ased on t hese vitals the patient could have been extremely dehydrated. There was no treatment provided or the information was not documented. Another patient seen on 4/7/13 was seen urgently for headache and chest pain. The patient had a pulse of 107 and a blood pressure of 168/120. T here was no documented treatment or disposition for this patient.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. The policy and procedure on acute and emergency care must be completed. 2. Patients requiring hospitalization should have their clinical care at the facility evaluated
in order to identify any process or clinical quality issues which are correctable. This can be part of the Quality Improvement program.
5. Chronic care.
a. LCJ shall develop and implement a w ritten chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care.
b. LCJ shall adopt and implement appropriate written clinical practice guidelines for chronic and communicable diseases, such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, consistent with nationally accepted guidelines.
c. LCJ shall maintain an updated log to track all inmates with chronic illnesses to ensure that these inmates receive necessary diagnosis, monitoring, and treatment.
d. LCJ shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates' individual medical records.
e. LCJ shall ensure that inmates with chronic conditions are routinely seen by a physician to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions.

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f. LCJ shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
5.a.
The chronic illness policy and procedure are still incomplete. The policy should include how inmates are enrolled into and out of the program; the frequency of visits; a method of including uncommon diseases; when laboratory testing is to be done for the first time; how the disease roster is to be used; and reporting methods.
5.b.
Clinical practice guidelines for chronic illness are not yet completed. I continue to recommend using Dr. Shansky to assist in this process and to use, as applicable, established NCCHC guidelines.
5.c.
A chronic illness spreadsheet exists but is incomplete. When I checked the list, I found people on the list who did not have a chronic illness and some individuals were inaccurately labeled. In part, this problem is exacerbated because the electronic record does not provide a list of persons with their diseases.
A chronic disease roster is available. It is manually derived by the chronic disease nurse. Every day this nurse reviews all intake screenings and enters a d isease category based on her interpretation of what the disease is. This list is provided to an advanced practice provider who then reclassifies all patients. T he chronic disease roster should be derived from licensed practitioner diagnosed disease not by suggested disease categories of the chronic disease nurse. This system is used because the current electronic record is not capable of providing a listing of patients by disease.
This results in a not very useful disease roster at a significant manpower expense. Because the roster is not useful, practitioners find other ways to manage patients. A s an example, the nurse practitioner who tracks and manages diabetics uses her own list for tracking diabetics. She develops her list from the diabetic accucheck list. Also other providers give her names of individuals who have diabetes. Even though the chronic disease nurse spends considerable time developing a t racking list at least one provider spends considerable time to create another more reliable list. The inability to obtain a roster of chronic illness list results in redundant and wasted work.

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The chronic disease lists are based on a nurse interpretation of intake screening information and are not accurate. The general medicine chronic disease list, for example lists murmur, blister, alopecia, and dog bite amongst other problems as chronic illnesses. These are not chronic illnesses. As well, the pulmonary list has no disease listed so it is not possible to determine from the list whether patients on the list have asthma, emphysema, sarcoid, or any other pulmonary disease. These diseases are very different illnesses.
The program has developed tracking sheets for diabetes and hypertension in order to track key monitoring values for these diseases. For diabetes the values tracked consist of microalbumin, hemoglobin A1c, lipid values, eye examination and foot examination. Blood pressure and creatinine should be included. This log is maintained manually by the chronic illness nurse with a considerable amount of effort. With a reasonable electronic record, this data could be obtained by a query upon request. Instead this chronic illness nurse spends most of her time maintaining a spreadsheet which could be done by a machine. The nurses time is better spent using a machine to obtain this data and then to spend her time interacting with patients to obtain improved control of their disease.
If the existing electronic record continues to be used, the program will have to develop an alternate way to track patients with chronic illness.
5.d.
Though CorrectTek is difficult to use, it does keep a record of care provided, including medication administration and provider visits. Chronic illness visits are not identified as such in the electronic record but I could acceptably navigate through the chart nevertheless.
5.e.
CHI has hired a chronic illness nurse who is tasked with tracking persons with chronic illness and ensuring that necessary diagnostic testing, monitoring, and treatment is accomplished. She has developed a tracking spreadsheet but has had difficulty in identifying the entire panel of inmates with chronic illness for the reasons specified in the previous paragraph. However, this nurse spends much of her time doing the clerical work just tracking patients.
Review of medical records of persons with chronic illness still demonstrate missing diagnoses,and dropped appointments, follow up errors, and lack of continuity. A s part of the Quality Improvement program, medical leadership should review samples of at-risk chronic illness patients to test the performance of the system and chronic illness program.
The management of patients with sickle disease and asthma was reviewed and needs improvement. Patients with sickle disease are not getting sufficient pain medication to control their disease. T he medical staff’s fear that inmates will misuse pain medication is creating a barrier to appropriate treatment of sickle disease. Patients reviewed had bone fide sickle disease and based on laboratory values were in crisis and were not receiving sufficient pain medication,

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In addition, patients with asthma are not receiving rescue inhalers based on standard of care. The standard of care is that all patients with asthma should have a short-acting beta agonist inhaler on their person for use when exacerbations or acute symptoms occur. The existing practice in the LCJ for some patients is to have the nurse provide access to the medication during medication administration. T his is inconsistent with standards of care because the patient does not have access when he needs the medication and can only obtain the medication when the nurse arrives for medication administration. Moreover, regular scheduled use of short acting beta agonists is not recommended. All patients with asthma should have a rescue inhaler on their person for use during episodic symptomatic episodes.
The lack of adequate disease management is partly related to lack of adherence to clinical guidelines. The jail can develop their own guidelines but for common illnesses these guidelines should be based on contemporary standards such as:
• American Diabetes Association Clinical Practice Recommendations • National Heart Lung and Blood Institute (NHLBI) hypertension guidelines (JNC VII) • NHLBI asthma guidelines: Guidelines for the Diagnosis and Management of Asthma • NHLBI cholesterol guideline: 3rd Report of the Expert Panel on D etection, Evaluation,
and Treatment of High Blood Cholesterol in Adults • NHLBI The Management of Sickle Cell Disease
The chronic illness management is not good. The first visit for chronic disease patients is mostly an episodic encounter that doesn’t establish an accurate history or physical examination based on the chronic illness of the patient. W hen guidelines are established the provider staff should receive training on expectations for evaluation and monitoring of patients.
5.f.
There is no infirmary in the jail. The 4th floor of the old jail is considered medical housing. However there is no program of identification or management of inmates with special medical needs, including disabilities, or those requiring skilled nursing. The Jail will need to identify a location where such inmates can be housed and then establish policy and procedure for managing such a unit.
There is a policy on infirmary care but it s tates that the 4th floor is not an infirmary but in all respects it is used as an infirmary. F or example, the policy explains that the 4th floor is to be used for respiratory isolation even though there are no negative pressure cells on the unit. The program has established procedures for monitoring on this unit but they are not written. I was told that anyone needing infirmary care goes to a hospital but based on the hospital log, this is not credible information.
The program still does not have a procedure for handling complex patients. The 4th floor beds are mostly used for mental health patients. Insulin dependent diabetics and all types of chronic illness patients including detoxifying patients are housed randomly throughout the jail. Sicker patients (e.g. patients vomiting, or with heart failure) are sometimes housed on the 4th floor but even these types of patients are housed throughout the jail. Because complex patients require frequent nursing interventions, it is best to house them in the same area to save nursing labor in

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managing these patients. As well, it is best for these patients to be near a nursing station so that nurses can respond quickly when an emergency occurs. G roups of patients that should be housed together include complex medical patients, patients with acute infections that need monitoring, insulin requiring diabetics (because they require nurse administered insulin injections), disabled persons, persons who are detoxifying, and pregnant women. T he health program should work with the Sheriff to identify housing where these patients can be housed together.
Wheelchair patients are housed on the 4th floor where there are ADA accessible showers. People who are not well controlled have to be housed in general population except for brief periods of time.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Policy and procedure and clinical guidelines for chronic illness management and special needs management must be developed.
2. Management of chronic illness should begin in intake with identification, acuity ranking and appropriate referral to a provider. There must be a mechanism to enroll patients and dis-enroll patients in the chronic illness program.
3. The providers must use a standardized method of recording problems in the electronic record which permits maintaining a roster of persons with chronic illness.
4. Physicians must manage chronic illness by seeing patients at appropriate intervals, renewing medication, and performing thorough evaluations pertinent to the chronic disease being managed.
5. Lab and other testing (EKGs) should be performed as indicated by appropriate guidelines at indicated intervals. This information should be interfaced with the EMR.
6. A system of management of patients with disabilities and serious medical problems equivalent to infirmary care must be established and codified in a procedure. S uch a system would include: a. Admission by a physician b. Tracking of these 4th floor patients by name and diagnosis c. Acuity ranking of patients d. Defined interval evaluations by nursing and medical staff e. Rules for management of types of patients f. Rules for who can be admitted to the unit g. Discharge criteria h. Discharge only by a physician i. Complete access to physicians j. Adequate nursing coverage k. Physical space that accommodates ADA type patients l. A manual of care for nurses on the unit

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6. Treatment and Management of Communicable Disease.
a. LCJ shall develop and implement adequate testing, monitoring, and treatment programs for management of communicable diseases, including tuberculosis ("TB"), skin infections, and sexually transmitted infections ("STIs").
b. LCJ shall develop and implement infection control policies and procedures that address contact, blood borne and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
c. LCJ shall continue to test all inmates for TB upon booking at LCJ and follow up on test results as medically indicated, pursuant to Centers for Disease Control ("CDC") Guidelines. LCJ shall follow current CDC guidelines for management of in mates with TB infection, including providing prophylactic medication when medically appropriate. I f directed by a ph ysician, inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and hospitalized or housed in an appropriate, specialized respiratory isolation ("negative pressure") room on-site or off-site. LCJ shall provide for infection control and for the safe housing and transportation of such inmates.
d. LCJ shall ensure that any negative pressure and ventilation systems function properly. Following CDC guidelines, LCJ shall test daily for rooms in-use and monthly for rooms not currently in-use. L CJ shall document results of such testing.
e. LCJ shall develop and implement adequate guidelines to ensure that inmates receive appropriate wound care. Such guidelines will include precautions to limit the possible spread of Methicillin-resistant Staphylococcus aureus ("MRSA") and other communicable diseases.
f. LCJ shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
6.a.
CHI has an infection control nurse. She tracks TB skin tests and is currently working with CHI leadership in development of the program. Tracking of TB skin test data is still a work in progress. The policy is to perform a Mantoux skin test on all incoming inmates. However, the

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data presented for TB skin testing does not reflect that all inmates were tested. There is currently no way for the IC nurse to identify persons who have not had their TB skin test not read. We discussed data which needs to be kept in order to obtain this data. Despite the fact that the data is not completely accurate, the surveillance data is significantly improved from the previous visit and this item is nearing substantial compliance.
The Infection Control nurse provides patient education for HIV, Hep A, B and C. The content of the education is good; brochures are used which can be given to patients. T he very positive program can be expanded to include MRSA and hygiene steps inmates may take to reduce infection.
6.b.
The infection control policy and procedure was presented for review. Multiple suggestions were given to bring this procedure into compliance.
6.c.
All inmates coming into the jail now receive a Mantoux skin test to screen for tuberculosis. While there are problems maintaining surveillance statistics, the program has made considerable progress in this area. Because there are no negative pressure cells in the jail, there can be no respiratory isolation and reference to this in policy should be removed. Any patient suspicious for contagious tuberculosis should be masked and immediately transported to a hospital for evaluation. E xisting tuberculosis policy should refer to the Centers for Disease Control and Prevention document Prevention and Control of Tuberculosis in Correctional and Detention Facilities, 2006.
6.d.
There is no negative pressure ventilation system at the jail. Nevertheless, current policy still references placement in respiratory isolation at the jail which is not possible under existing conditions. All patients suspicious for contagious tuberculosis should be masked and immediately transported to a hospital for evaluation.
6.e.
Surveillance data for methicillin resistant staph aureus (MRSA) is obtained by the infection control nurse from culture data and by reviewing the urgent care log to determine who might have been treated for MRSA. The providers are not reporting MRSA treatments which means that MRSA is most likely under reported. The procedure on MRSA and actual practice should provide a method to capture all cases of treatment for MRSA both presumed and culture positive.
Treatment guidelines should reference local board of health recommendations based on l ocal sensitivity patterns.

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6.f.
A nurse is assigned to infection control. Surveillance data for MRSA is obtained from culture data and from treatment records in the urgent care log. Also, MRSA is not reported by housing units. This is important if the surveillance data is to be used to prevent infections from spreading by improving sanitation of cells. For tuberculosis screening, data is extracted, at considerable manpower expense, from the electronic record. The program has demonstrated ability to do this but needs to clean up the data so that inmates who are discharged before having skin tests read and previously positive skin tests patients are recorded. Data for STDs is obtained from culture results (chlamydia, gonorrhea, syphilia). HIV, hepatitis is both lab data and self-report.
Data is now reported to the QI Committee. This is an appendix of monthly QI Committee meetings. Data reported to QI should include the number of positive skin tests and any suspicious or positive TB disease. Rates of skin test positivity should be derived and reported to QI. The program does not work with the local department of health in developing a surveillance plan.
RECOMMENDATIONS FOR NEXT 6 MONTHS:
1. Revise the Infection Control procedures considering comments in the policy section of this report. This plan should also include Occupational Health and Safety required blood borne pathogen practices and isolation procedures in the event of an airborne contagious disease event.
2. Review and edit the vaccination procedures for influenza in consideration of existing ACIP guidelines.
3. Develop airborne isolation procedures consistent with Centers for Disease guidelines.. 4. Establish surveillance tracking of tuberculosis, skin test rates, conversion rates, employee
conversion rates, and MRSA rates. T hese data should be sent routinely to the Quality Improvement committee at least quarterly.
7. Access to Health Care.
a. LCJ shall ensure inmates have timely and adequate access to appropriate health care.
b. LCJ shall ensure that the medical request ("sick call") process for inmates is adequate and provides inmates with adequate access to medical care. The sick call process shall include:
(1) written medical and mental health care slips available in English, Spanish, and other languages, as needed;
(2) a confidential collection method in which the request slips are collected by Qualified Medical Staff seven days per week;
(3) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and

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(4) opportunity for all inmates, irrespective of primary language, to access medical and mental health care.
c. LCJ shall ensure that the sick call process includes logging, tracking, and timely responses by Qualified Medical Staff. The logging procedure shall include documentation of the date and summary of each request for care, the date the inmate was seen, 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. LCJ shall document the reason for and disposition of the medical or mental health care request in the inmate's medical record.
d. LCJ shall develop and implement an effective system for screening medical requests within 24 hours of submission. LCJ shall ensure sick call requests are appropriately prioritized based upon the seriousness of the medical issue.
e. LCJ shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
f. LCJ shall ensure that there is an adequate number of correctional officers to escort inmates to and from medical units to ensure that inmates requiring treatment have timely access to appropriate medical care.
g. LCJ shall ensure that Qualified Medical Staff make daily rounds in the isolation areas to give inmates in isolation adequate opportunities to contact and discuss medical and mental health concerns with Qualified Medical Staff in a setting that affords as much privacy as reasonable security precautions will allow. During rounds, Qualified Medical Staff will assess inmates for new clinical findings, such as deterioration of the inmate's condition.
h. LCJ shall revise its co-pay system in terms of amount and waivers and such policy will clearly articulate that medical care will be provided regardless of the inmate's ability to pay. No fee-for-service shall be required for certain conditions, including health screenings, emergency care, and/or the treatment and care of conditions affecting public health, e.g., Tuberculosis, MRSA, pregnancy, etc., particularly for indigent inmates who are not covered by a health insurance plan or policy.
OVERALL COMPLIANCE RATING: Substantial Compliance

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ASSESSMENT:

7.a-b

Progress continues on this item and it is just barely substantially compliant. The policy and procedure on this item are not yet complete. The slips are now available in English and Spanish. For languages other than Spanish or English, the program utilizes a telephonic interpretative service that can offer translator services in any language. Patients with cognitive impairment are seen 3 times a week by a nurse who asks if the patient has a problem. The program is working on ways to improve access for illiterate inmates.

7.c-d

The program does log and track sick call requests. T he program has created a “sick call log” which is a defined template in the electronic record. Information on hand written slips is entered into a template called “sick call log” which includes the complaint type, the complaint, the date collected, triage date (face to face), the triage t ype, symptoms, the triaged acuity level, the response, and date scheduled for a provider, and whether the patient was seen in primary care by date. The log was reviewed and is adequate.

Sick call requests are evaluated M-F with paper triage on w eekends. D ocumentation of nurse FTF evaluations is a SOAP note documented on a blank form in the electronic record.

The log can be used to monitor quality of nurse evaluation. The number of slips for the month of March is listed below in a table. As can be seen, the mental health requests are nearly equivalent to medical requests.

# in March
% in March

Medical 360 48%

Dental 92
12%

Mental Health
304
40%

The data provided is that 100% of slips are triaged within 24 hours. I did find in earlier time periods, on chart review, where some slips were not triaged timely. Follow up of this item will be performed, but clearly this is an improvement over prior visits.

7.e.

All face-to-face evaluations are done in a clinic setting. In addition to the clinic examination rooms in the 4th floor clinic area there are several rooms in housing units where nurses can conduct sick call evaluations. I inspected one of these rooms. It was properly sized and equipped but was cluttered and not sanitized properly.

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There is a single sick call nurse who picks up all slips in the morning, triages all slips and then gives a list to custody so that by noon they bring patients to one of the designated examination rooms for evaluation.
On chart reviews, ten episodes of sick call requests were evaluated. The sick call nurse performed very well on her evaluations. T he weekend nurse needs to improve documentation and there were other problems identified on these reviews.
Four of the ten were appropriately evaluated. In five of the ten requests, the inmate refused to be seen after placing the request. This is one of the highest rates of refusal that I am familiar with. This is consistent with comments by medical staff that there are high rates of refusal for medical services. In one of these, the officer reported that the inmate didn’t need to be seen. Officers should not be involved in judgments regarding whether an inmate needs to be seen or not.
The high rate of refusals is extraordinary. I interviewed one of the inmates regarding his refusal. He indicated that the reason he refused was because he didn’t want to wait in the waiting room on the 4th floor clinic area. This room is a small room approximately 10 by 10 feet. I walked into the room and the smell was overpowering. It appeared to have no ventilation. Additionally, I witnessed this room when well over a dozen people were in this room making inmates stand very close one to another. They may have to wait in excess of an hour in these conditions. Clearly, this is a barrier to access to care. In any case the program should investigate why there is such a high rate of refusal and attempt to remedy this barrier to access.
In one of the four nurse evaluations, the evaluation occurred on t he week end. T he documentation was poor. As a result of the nurse evaluation, an antibiotic was started, but there was no ph ysician order and the nurse documentation did not describe a physician order or the indication for the clindamycin. It appears from documentation that the nurse prescribed the medication.
In another chart reviewed, the nurse did an appropriate evaluation and referred the patient to a provider to evaluate for the need for an asthma inhaler. T he scheduled appointment with the provider occurred but the provider did not address the complaint. It is not even clear that the provider knew why the patient was scheduled for the appointment.
7.f.
There are no perceived problems related to officers moving detainees for clinic evaluations. This is a significant improvement over previous visits. A lthough the refusal problem exists, the availability of officer transport is significantly improved.
7. g.
Nurses make segregation rounds in the jail 3 times a week. They utilize a segregation list that they obtain from custody. H owever these rounds are not logged on the units. Segregation rounds are documented in the electronic record for each individual who is in segregation. Segregation rounds should be documented on the units where inmates are housed.

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7. h.
The co-pay practice has been modified so that sick call request charges are only for sleep medication, ear wax treatment, and $3 for a prescription medication.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Sick call policy and procedure must be completed. 2. Slips that include symptoms must include a nurse face to face evaluation in a clinical
setting. This should occur no later than 72 hours based on the clinical issue. 3. Nurse protocols for evaluations should be developed. T hese must be approved by the
Medical Director.
5. Follow-Up Care.
a. LCJ shall provide adequate care and maintain appropriate records for inmates who return to LCJ following hospitalization.
b. LCJ shall ensure that inmates who receive specialty or hospital care are evaluated upon their return to LCJ and that, at a minimum, discharge instructions are obtained, appropriate Qualified Medical Staff reviews the information and documentation available from the visit, this review and the outside provider's documentation are recorded in the inmate's medical record, and appropriate follow-up is provided.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
8. a-b.
The hospital policy is in place but does not address where returning patients are seen, how new medication is started, or how the follow up physician visit is scheduled and when the follow up visit is scheduled. In practice, it a ppears that it is clear where patients return, but the policy should state this.
Inmates returning from offsite visits, in practice, are returning to intake and are seeing a nurse. This appears to occur for all patients. The nurse does not always document understanding of why the patient had been off site, particularly for hospitalizations. O n chart review, the physician review sometimes did not include a review of what had transpired at the hospital or specialty clinic. A lso, it did not appear that the physician updated the patient on w hat had occurred during the off-site event. The provider follow up piece is still deficient in this process.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Upon return from the hospital or off-site consultation, all patients should go to a standard central location and be evaluated by a nurse and physician. If a physician is not present, the nurse should evaluate the patient and consult with a physician regarding any change in therapy. This discussion should be documented in the medical record.
2. The patient should be scheduled for a follow up physician visit to discuss and evaluate disease status.
3. For quality purposes, the log should be evaluated monthly to assess whether follow up is occurring as indicated.
4. The inmate must be evaluated for renewal of medication or change in therapy based on the outside visit. The nurse must consult with a physician for these orders.
9. Emergency Care.
a. LCJ shall ensure that Qualified Medical and Mental Health Staff are trained to recognize and respond appropriately to medical and mental health emergencies. LCJ shall train correctional officers to recognize and respond appropriately to medical and mental health emergencies. LCJ shall ensure that all inmates with emergency medical or mental health needs receive timely and appropriate care, including prompt referrals and transports for outside care when medically necessary.
b. LCJ shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation ("CPR") and addressing serious bleeding) in emergency situations. LCJ shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
OVERALL COMPLIANCE STATUS: Partial Compliance
ASSESSMENT:
9.a.
The emergency care policy is not yet complete. Once completed, if satisfactory, this item should move to compliance.
The training syllabus is complete and is satisfactory. I was unable to verify the numbers of officers trained. T his will need to be provided in aggregate as a number of officers trained divided by the number of officers.

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9.b.
I randomly checked a control station on one of the tiers. The control room had a first aid kit, including mask and gloves. A n oxygen tank was also present on t he unit. T he supplies were marked, secured and orderly.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Complete the emergency response policy.
10. Record Keeping.
a. LCJ shall ensure that medical and mental health records are adequate to assist in providing and managing the medical and mental health needs of inmates at LCJ.
b. LCJ shall develop and implement policies, procedures, and practices to ensure timely responses to orders for medications and laboratory tests. Such policies, procedures, and practices shall be periodically evaluated to ensure timely implementation of clinician orders.
c. LCJ shall ensure that medical and mental health records are centralized, complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
d. To ensure continuity of care, LCJ shall submit appropriate medical information to outside medical providers when inmates are sent out of LCJ for medical care. LCJ shall obtain records of care, reports, and diagnostic tests received during outside appointments in a t imely fashion and include such records in the inmate's medical record or document the inmate's refusal to cooperate and release medical records.
e. LCJ shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
10.a.
Some improvements to the electronic medical record have been made. The integration with the pharmacy has been completed. A sick call template is in use which permits tracking of health request data. However, staff continue to find the product very difficult to use. Requirements of

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this agreement include production of data which has not been possible to obtain directly from the electronic record such as a chronic illness roster and infection control surveillance data. Much effort has been made both on the part of the Sheriff’s staff and the medical contractor staff to obtain the necessary data. In addition, both the Infection Control nurse and the Sick Call nurse spend almost all their time performing clerical work to obtain data that typically would be provided by an electronic record. The work that these individuals should be performing to obtain compliance under this agreement is thus diverted to a cl erical function made necessary by a product unable to provide information as needed.
The electronic record still appears to permit more than one staff to document on the same note. The electronic record does not lock the user to a single user. S taff were inconsistent in their response as to whether locking records to a single user was possible or not. If this is possible, then training is an issue. If it is not possible to lock records, there is a major problem with the electronic record. The program needs to resolve this issue.
It is extraordinary the extent to which staff have created work-a-rounds in order to make the existing electronic record useable.
10.b.
Policies and procedures on timely responses to orders for medication and laboratory tests need to be developed. T hese should include physician co-signature for verbal orders. The downtime procedure needs some revisions. It does not provide direction for when paper records are to be used, where the paper records are to be obtained and who gives approval to start using paper records when the electronic record is not functioning. This procedure should be revised.
10.c.
An electronic record is in use. Medical providers do have access to the record and the record is accessible to nurses as they administer medication. Laboratory results are now electronically interfaced with the record.
10.d.
When a patient goes out to a hospital, a MAR is sent with them along with “hospital transfer paperwork” which includes medical history filled in by a nurse who may or may not know the reason for sending the patient to the hospital or specialist. Medications are also included.
The facility has continued problems getting medical information back from the hospital. Much time is spent getting this information. On chart reviews, it is still evident that when physicians see patients return from the hospital or from offsite consultation they either do not have the consultant or hospital record or are not documenting that they have reviewed this information.

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10 e.
The electronic record is unified but is not completely electronic. Some elements are scanned into the record.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should consider an alternate electronic record or definitively correct existing patient safety issues.
2. Software training should occur when new employees start work as part of the orientation. 3. A system of tracking software issues should be instituted to ensure that software
problems are solved. 4. A manual back up s ystem should be in place in the event the software goes down.
Instructions in the event of software crashes should be documented in a “down time procedure”.
11. Medication Administration.
a. LCJ shall ensure that inmates receive necessary medications in a timely manner.
b. LCJ shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. LCJ shall provide a systematic physician review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his or her condition.
c. LCJ shall ensure that medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. LCJ shall ensure that medication administration is performed by Qualified Nursing Staff who shall administer prescription medications on a directlyobserved basis for each dose, (unless the physician's order notes that the inmate can self-administer the medication), shall not discontinue medications without a physician's order, and shall accurately document medication orders as being ordered via telephone. Qualified Nursing Staff shall practice within the scope of their licensures.
e. When LCJ has advance notice of the discharge of inmates with serious medical or mental health needs, LCJ shall provide such inmates with at least a sevenday supply of appropriate prescription medication, unless a different amount is deemed medically appropriate, to serve as a br idge until inmates can arrange for continuity of care in the community. LCJ shall supply sufficient medication for the period of transit for inmates who are being transferred to another correctional facility or other institution. LCJ shall prepare and send with transferring inmates a transfer summary detailing major health problems and

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listing current medications and dosages, as well as medication history while at LCJ. LCJ shall ensure that information about potential release or transfer of inmates is communicated to Qualified Medical and Mental Health Staff as soon as it is available.
f. LCJ shall create a f ormal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications.
g. LCJ shall ensure that Qualified Medical Staff counsels all patients who refuse medication.
h. LCJ shall secure the medication room and discontinue allowing food to be stored in the medication refrigerator.
COMPLIANCE ASSESSMENT: Substantial Compliance
ASSESSMENT:
11.a.
The program is able to track prescription order times and compare them to first dose delivery time. Approximately 99% of the time this time occurs within 24 hours. On chart review, I did not identify any patient who did not receive medication within 24 hours for the first dose.
11.b.
The medication policies were reviewed and discussed with leadership. Under this policy officers are permitted to administer and deliver medication. A s well, officers are allowed access to stored narcotic medication. N either of these procedures should be permitted. O fficers should not be involved in administration or delivery of medication and should not be permitted access to stored narcotic medication. In reality, I believe that this does not happen, but the policy should be corrected.
Also, the procedure for medication renewal may be prone to problems. This was discussed with the leadership. Currently, a report of all medication that is expiring within 14 days is given to a scheduling nurse who schedules the patient to the provider clinic. If the patient refuses clinic twice, the renewal is dependent on t he chronic clinic nurse to identify that the medication is expiring. Given the very high refusal rate, it is possible that medication expires because inmates are not seen. It would be better if notice of expiring medication were given to providers so that they could review the record, decide if a patient needed to be evaluated and to renew medication if indicated.
The procedure for medication administration did not include specific steps the medication assistant follows in administration of medication.

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11.c.
Documentation of administration of medication is recorded at the time medication is administered. I was told that participation of officers in medication administration has improved significantly since the Deputy Warden of Security issued a memo to correctional staff clarifying their responsibilities during medication administration. T his could be improved further by development of an interagency procedure resulting in post orders. During the medication administration I observed, however, there was no officer present to assist the nurse because there was no available cross watch officer. W hile we were waiting for a replacement officer, a custodian officer offered to assist. Medication was administered with the three inmate workers standing nearby. T he monitoring of inmate’s swallowing medication was less than optimal; it would not be surprising to find that inmate’s are hoarding medication as swallowing of medication was not ensured.
The 5 rights of medication administration were acceptably followed. The medication packet the nurse administers from is labeled by the pharmacy. T he inmate name is verified from a wristband or by an identification card that the officer holds. The nurse verifies the inmate name, returns to the eMAR to verify medication information and correct patient and then verifies that the labeled medication packet is correct. T he medication assistant could improve hygiene by periodically sanitizing her hands. I did not notice the nurse directly handling medication, but sanitizing hands before beginning work on a unit would be appropriate.
11.d.
Medication administration is performed by medical assistants. T hese individuals all have a certificate on file. I still have not yet been provided with State regulations which permit use of medication assistants as capable of administering medication. Nursing staff do t ake verbal orders from physicians. When this occurs, documentation of that verbal order has to be in a progress note which I did not consistently find. Data provided to me shows that 78 verbal order prescriptions from April 29th to May 3 were not as yet co-signed by a physician. I could not find evidence of physician co-signing of verbal orders in the record.
11.e.
LCJ states that it provides 7 days of medication to inmates who are discharged. This is performed for planned discharges. Because the health program seldom knows when an inmate is being discharged, few if any inmates receive discharge medication.
11.f.
There is a pharmacy and therapeutic committee meeting with minutes. They have minutes for these meetings. It occurs separate from the CQI meeting. These minutes were in the CD ROM. A formulary is in place but has some restrictions. Peridex, for example, is a typical antibacterial used for persons with gingivitis but is not permitted. Mostly, barriers to medication are not via formulary restrictions but practice decisions. For example, asthmatics are systematically denied access to keep-on-person beta agonist rescue inhalers. Use of pain medication for sickle disease

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is severely restricted. Both of these practice decisions result in barriers to standard of care practice.
11.g.
The new medication policy is adequate regarding medication refusals. I did not observe medication refusal on chart reviews. The custody memo from the Deputy Warden directs that all refusals are to be made directly face to face to the nurse.
11.h.
Significant improvement has been made in regards storage of medication and cleanliness of the medication room.
RECOMMENDATION FOR NEXT 6 MONTHS:
1. In addition to the medical medication administration policy, there should be an interagency procedure which specifies the responsibilities of custody and medical staff in medication administration. A start has been made on the policies but some additional work needs to be done.
2. Medication administration must be standardized and facility specific. 3. Storage of medication carts should be in a secured area, away from civilians and inmates. 4. Medication renewal should include evaluation of the patient and should be facility
specific and codified in procedure.
12. Medical Facilities.
a. LCJ shall ensure that sufficient clinical space is available to provide inmates with adequate medical care services including:
(1) intake screening; (2) sick call; (3) physical assessment; and (4) acute, chronic, emergency, and speciality medical care (such as geriatric
and pregnant inmates).
b. LCJ shall ensure that medical areas are adequately cleaned and maintained, including installation of adequate lighting in medical exam rooms. LCJ shall ensure that hand washing stations in medical areas are fully equipped, operational and accessible.
c. LCJ shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and sharp medical tools) and hazardous waste.

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d. LCJ shall provide for inmates' reasonable privacy in medical care, and maintain confidentiality of inmates' medical status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
12.a.
Significant renovation has taken place and this item is near substantial compliance. The intake area was renovated to now include 3 i nterview booths. T he purpose of these booths was to ensure privacy. T he construction occurred in a room with concrete or block walls. A conversation in these booths echoes throughout the room so that there is no ve rbal privacy. Because everything else about the room is adequate, I suggest the program install sound baffling to muffle the sound. The examination room in this area is adequate.
On the 4th floor the dental unit has been renovated and is adequate. Similarly, the compressor was placed in a closet but the sound of the compressor is quite loud. Sound baffling should be placed on the door and walls of the closet to reduce sound transmission. The air vent opening must, however, not be covered so that the machine functions properly.
There is still no i dentified location to perform detoxification and to house medically complex patients. I was told that once mental health abandons the 4th floor, the 4th floor will be used for this purpose.
The clinic rooms in the 4th floor are acceptably remodeled to permit private examinations. Staff must utilize the ability for privacy to actually conduct examinations in private.
Showers on the 4th floor have been modified so as to provide ADA acceptable showers.
12.b.
The clinics were cleaner. However, some rooms were cluttered and not sanitized. The dental operatory floor was soiled and had trash in the can. The last use of this clinic had been a week previous so this indicates lack of sanitation. One of the nursing sick call examination rooms on the 3rd floor was also cluttered and not sanitized. Since the clinics are newly renovated, I would suggest that the health program work with the Sheriff to develop a sanitation schedule appropriate for health care units and ensure that this is done. Weekly inspections of the areas should be done to ensure that sanitation is being performed.
12.c.
I did not inspect biohazard containers this visit.

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12.d.
Privacy of care is now possible, but I did notice staff not taking advantage of privacy and conducting examinations in the presence of officers or other staff. This is a training issue.
RECOMMEDNATIONS FOR THE NEXT 6 MONTHS:
1. The intake medical screening booths should have some type of sound baffling to ensure sound privacy.
2. Develop a plan for medical and mental health higher acuity care housing. 3. Determine a single location for detoxification and insulin requiring patients which is near
to the nursing station. 4. Standardize sanitation schedules and include monitoring of sanitation as part of QI. 5. Make adjustments to the waiting room on the 4th floor so it is not a barrier to access.
13. Specialty Care.
a. LCJ shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at LCJ shall receive timely referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. LCJ 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 Qualified Medical Staff as medically necessary, at intervals of no more than 30 days, to evaluate the current urgency of the problem and respond as medically appropriate.
c. LCJ shall maintain a c urrent 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, the reason for any missed or delayed appointments, and information on follow-up care, including the dates of any future appointments.
d. LCJ shall ensure that pregnant inmates are provided adequate pre-natal care. LCJ shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment, and management of high risk pregnancies.
OVERALL COMPLIANCE RATING: Partial Compliance

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ASSESSMENT:
13.a-b.
There is now a nephrologist and no t rouble with dialysis appointments. T here is a consultant cardiologist. There aren’t requests for dermatology but there is no available dermatologist. There have been problems with the obstetrician and the program is in the process of obtaining another obstetrician. There have been several cancellations of obstetrical appointments. There are no current backlogs in any specialty.
Verification of timeliness of specialty appointments is not possible with the existing tracking system. The spreadsheet does not capture the date a specialty appointment was first ordered but only the latest date of order. For example, if an appointment was ordered 1/14/13 and cancelled on 2/4/13 and then re-ordered 2/6/13, the spreadsheet will indicate that the appointment was ordered 2/6/3. Thus, appointments can be repeatedly cancelled and it will appear on the tracking sheet that they are timely. I discussed with the IT person for the medical program how this could be corrected so that specialty appointments can be verified as being timely. This is a major barrier to substantial compliance along with a stable obstetrical consultant.
13.c.
The log does now track cancelled appointments. The appointment order date is still not on the log. The appointment rescheduled date is also not on t he log. For January there were 25 appoiutments; 18 were seen, 4 were released, 1 inmate refused and 1 was cancelled. T he 1 appointment cancelled was rescheduled but the patient was discharged before he could be seen. For January through March there were 3 cancellations. 2 were seen and 1 was discharged before being seen. There were 4 cancellations of obstetrical appointments over this time period.
13.d.
There have been problems with the obstetrician and the leadership is negotiating with a new obstetrician. Policies still need to be modified so that the proper list of laboratory tests required is in the procedure. T esting should follow American College of Obstetrics and Gynecology standards (ACOG).
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The program should finalize arrangements for obstetrical consultations. 2. Specialty appointments which are cancelled because of lack of transport officers should
be tracked and reviewed by the Quality Improvement Program. The time from provider order to the appointment should be tracked and reviewed for appropriateness by the Medical Director. The date of provider order for specialty care should be tracked on the specialty log.

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3. Persons who fail to go to a scheduled appointment should be tracked and the reason for the missed appointment should be provided. This information should be provided to the Sheriff on a regular basis.
4. Pregnant females should be evaluated by an obstetrician within a week of incarceration. Prenatal lab tests can be performed routinely upon incarceration so that they will be available to the obstetrician and primary care providers at the facility.
5. Information from the obstetrician should be exchanged with the medical staff at the jail and scanned into the medical record.
6. Someone on site should be capable of performing a routine pregnancy visit for pregnant females so that care can be managed along with the obstetrician. Clinical assessment items should be standardized so that onsite staff know what to evaluate.
14. Staffing, Training and Supervision.
a. LCJ shall ensure that its health care structure is organized with clear lines of authority for its operations to ensure adequate supervision of the system's health care providers.
b. LCJ shall maintain sufficient staffing levels of Qualified Medical Staff and Qualified Mental Health Staff to provide care for inmates' serious medical and mental health needs
c. LCJ shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious medical and mental health needs of inmates. All such staff shall receive documented orientation and inservice training on relevant topics, including identification of inmates in need of immediate or chronic care, suicide prevention, and identification and care of inmates with mental illness. LCJ shall ensure that all other medical and mental health staff receive adequate training to properly implement the provisions of this Agreement.
d. LCJ shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.
e. LCJ shall ensure that all persons providing medical or mental health treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, LCJ shall verify that all medical or mental health staff have current, valid, and unrestricted professional licenses.
f. LCJ shall ensure that correctional officers are adequately trained in identification, timely referral, and proper supervision of inmates with serious medical needs. LCJ shall ensure that correctional officers are trained to understand and identify the signs and symptoms of drug and alcohol withdrawal and to recognize and respond to other medical urgencies.

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g. LCJ shall ensure that correctional officers receive initial and periodic training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); recognition of signs and symptoms evidencing a response to trauma; appropriately responding to mental illness; proper supervision of inmates suffering from mental illness; and the appropriate use of force for inmates who suffer from mental illness. Such training shall be conducted by a Qualified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
14.a.
CHI has a good leadership team and lines of authority are clear and understood by all. T he program would benefit by structured performance reviews of providers. The review of providers does not include clinical performance review. Reviews of chronic illness history and physical examination should be done as this is the area of greatest deficiency.
14.b.
A staffing plan was reviewed. There are 46 full time equivalent staff which seems reasonable. It appears adequate with a couple of exceptions. There appears to be insufficient dental hours.
Additionally, the withdrawal procedures and infirmary care management have not yet been started and it is not certain therefore that there are sufficient staff to do this.
14.c.
A spreadsheet is maintained which lists whether training and personnel items are up t o date. This sheet includes credentials, license, blood borne pathogen training, CPR training, suicide prevention training, and emergency response training. This folder is well maintained.
14.d.
The physician assistant has to have 100% of charts reviewed for the first year, 50% the 2nd year, and 25% the 3rd year, and 25% thereafter for the purpose of licensure. This review was behind schedule year to date. Nurse practitioners are required to have 5% of charts reviewed which are also behind year to date. The reviews are of random charts. The review consists of looking at the Subjective, Objective, Assessment and Plan for each chart reviewed. Comments are made on each review. All comments to the providers are made verbally. There is no documentation to the provider. T he Medical Director keeps a log of charts reviewed. There should be a documented report of these reviews. There is no physician performance evaluation which should occur.

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14.e.
All licensure information for clinical staff is maintained up to date in an “employee credentials” notebook which was reviewed and is up t o date. Leadership tracks credentials, blood borne pathogen training, suicide prevention training. An on-line blood borne pathogen training course is utilized for all staff. Certificates are in the tracking log. All credentials were checked and are up to date. Physician National Practitioner Data Bank information was unable to be obtained for this visit due to enrollment issues.
14.f.
The medical program developed a training program for officers on how to recognize medical emergencies. I was told that 97 % of officers have had training on r ecognition of medical emergencies but did not verify this data.
14.g.
Refer to Dr. Metzner’s report.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. A proper orientation program should be put into place for all employees. T his should include orientation to policies and procedures, security rules, and training necessary for functional competency (electronic record training, OSHA training, etc.). A record of training on policies and procedures should be in place.
2. CHI should monitor the ability to perform required sick call request evaluations and performance under the withdrawal protocol and assess whether staffing is adequate. Also, care of the infirm on the 4th floor needs to be evaluated relative to staffing. This can’t be done until policies and procedures are finished.
3. Provider credentialing must include National Practitioner Databank information. 4. Officer training must be tracked including name of officer, dates training occurred, and
type of training given. Summary statistics of aggregate numbers of officers trained and not yet trained should be provided.
15. Dental Care.
a. LCJ shall ensure that inmates receive adequate dental care, and follow up. Such care should be provided in a t imely manner. Dental care shall not be limited to extractions.
b. LCJ shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.

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OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
15.a-b
The dental unit has been renovated and is adquate. It still appears that there are insufficient dental hours. T here are 8 hour s of dental time. F or the month of April there were 81 de ntal requests. Yet, in April the dentist saw 54 patients or approximately 13.5 patients a week. There is no tracking of dental requests and it was difficult to determine adequacy of staffing in this area but it appears from the need that insufficient numbers of patients are seen. T he timeliness of dental requests were not evaluated. T he many dental refusals seem unusual and should be examined. The dentist does not prioritize dental requests. Dental requests that include pain are now evaluated by a nurse. Medication is provided pending the dental appointment.
RECOMMENDATIONS:
1. Dental requests should be prioritized by the dentist. 2. Patients with dental pain should not exceed a week in waiting.
16. Mortality Reviews.
a. LCJ shall request an autopsy, and related medical data, for every inmate who dies while in the custody of LCJ or under medical supervision directly from the custody of LCJ.
b. LCJ 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 LCJ personnel and shall seek to determine whether there was a pattern of symptoms that might have resulted in earlier diagnosis and intervention. Mortality and morbidity reviews shall occur within 30 days of the incident or death, and shall be revisited when the final autopsy results are available. At a minimum, the mortality and morbidity reviews shall include:
(1) critical review and analysis of the circumstances surrounding the incident;
(2) critical review of the procedures relevant to the incident; (3) synopsis of all relevant training received by involved staff; (4) pertinent medical and mental health services/reports involving the
victim; (5) possible precipitating factors leading to the incident; and (6) recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures.

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c. LCJ shall address any problems identified during mortality reviews through timely training, policy revision, and any other appropriate measures.
OVERALL COMPLIANCE RATING: Partial Compliance
ASSESSMENT:
16.a-c.
There were two deaths in the calendar year. For each death there was an autopsy.
The deaths were February 8th 2013 and the second was March 4th 2013. The mortality reviews were not yet available at the time of our visit. I sat in on a mortality review meeting on 5/8/13. All key personnel attended this review including custody staff. The custody reports should be incorporated into the timeline of events leading up to the death. The discussion was good. It remains to be seen whether problems identified in the discussion are described in the report and if appropriate corrective action results.
RECOMMENDATIONS FOR NEXT 6 MONTHS: 1. The mortality review should result in a document that gives recommendations for improving aspects of care that were deficient as identified in the mortality review. 2. The mortality review policy and procedure should be completed.

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B. MENTAL HEALTH CARE: Settlement Agreement Part III Section B
1. LCJ shall provide adequate services to address the serious mental health needs of all inmates, consistent with generally accepted correctional standards of care, including sufficient staffing to meet the demands for timely access to an appropriate mental health professional, to ensure qualified mental health staff perform intake mental health screenings and evaluations, and to perform comprehensive assessments and comprehensive multidisciplinary treatment planning. See Section III. A.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: As of May 6, 2013 the 19.2 FTE QMHP FTE allocated positions were allocated as follows:
1.0 FTE PNP Psychiatric Nurse Practitioner, MSN, RNC, CNS 2.0 FTE QMHP Mental Health Director, Ph.D., LMHC, LMFT, LCAC 3.0 FTE QMHP Clinical Supervisor, MS, LMHC, LCAC 1.0 FTE QMHS Mental health Team Leader, B.A. (MSW in progress) 2.0 FTE QMHPs LCSW, LMHC, LCAC 5.0 FTE QMHP-C (Candidates for LMHC and LCSW) 8.2 FTE QMHS, Crisis Stabilization/Suicide Counselors, B.S. (4 graduate May M.S.)
The above represents a decrease of a 0.2 FTE QMHP-C.
My October 2012 report included the following:
In general, it appears that the current staffing allocation is adequate for LCJ to perform the required mental health screening process (if the timeframes for routine referrals are changed) but not adequate to provide services to address the serious mental health needs of all inmates for reasons that will be summarized elsewhere in this report.
My opinion re: the above is unchanged.
The psychiatrists’ allocation will be further discussed in a later SA provision of this report (see section B.3.e.).
Mr. Ray and Terry Harman, LMHC indicated that a staffing analysis will be performed once the new mental health unit is opened.
May 2013 Recommendations for next 6 months:
Perform the staffing analysis re: the number of FTE mental health positions necessary to comply with the various provisions of this Settlement Agreement (SA).

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2. Timely and Appropriate Evaluation of Inmates.
a. LCJ shall develop and implement policies and procedures to provide adequate screening to properly identify and assess inmates with mental illness, and evaluate inmates' mental health needs. See also Section III.A.2.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Mental health policies completed by Lindsay Hayes and signed by the Sheriff, Dr. Forgey and Dr. Harman since October 2012 included the following:
16.01 Governance 10.22.12 16.01.02 Access to Care 3.20.13 16.01.06 Policies & Procedure 3.20.13 16.02 Safety 10.22.12 16.03 Personnel & Training 10.22.12 16.04 Healthcare & Support 10.22.12 16.05 Inmate Care & Treatment 10.22.12 16.06 Health Promotion 10.22.12 16.09.01 Clinically Ordered Restraint 10.18.12 revised 3.22.13 16.09.02 Emergency Psychotropic Medication 3.20.13
Other policies and procedures, as previously summarized in the September 2011 report, that still need to be developed and implemented, include the following topic areas:
1. Mission and goal 2. Administrative structure 3. Staffing (i.e., job descriptions, credentials, and privileging) and staffing plan 4. Involuntary treatment including the use of forced medications, and involuntary
hospitalization 5. Other medicolegal issues including informed consent and the right to refuse treatment 6. Limits of confidentiality during diagnostic and/or treatment sessions with pertinent
exceptions described 7. Mental health record requirements 8. Quality assurance and/or improvement plan 9. Research protocols
May 2013 Recommendations for next 6 months:
The recommended draft policies and procedures need to be completed.
b. LCJ shall ensure that the intake health screening process referred to in Section III.A.2 includes a mental health screening, which shall be incorporated into the inmate’s medical records. LCJ shall ensure timely access to a Q ualified Mental Health Professional when presenting

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symptoms of mental illness require such care.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

May 2013 Assessment: The CorrecTek (CT) issues preventing the data collection for the MH Intake Process reported in the October 2012 report have been resolved.

The 3.22.13 audit by Lindsay Hayes includes the following comment relevant to the booking process:

The Mental Health/Suicide Risk Intake Screening Form has been revised (based upon consultation with the DOJ monitor) to better assist intake nurses with the mental health referral process. As a result, almost all of the 17 intake questions will provide guidance for an immediate, 24-hour, or 72-hour referral requirement to mental health staff. In addition, the “Observation of Mental Status” section of the form was slightly revised. The revised form was sent to CorrecTek for inclusion into the electronic medical record. The revised form should be available for use in April 2013.

Early in 2012 the referral rate of inmates to the mental health department reached 82%. The above measures brought the rate down to 66% in December 2012 for an overall 2012 rate of 64%. The first three months of 2013 indicate an average referral rate of approximately 52% (see below).

JAN FEB MAR APR SRA REFERRALS 14 17 10 9 MHE REFERRALS 609 573 553 567

YTD AVG 50 12.5 2302 575.5

The referral rate of inmates to the mental health department from intake has decreased but still remains very high. The recent refinement of the screening instrument and further training of the intake nurses should help further reduce the referral rate.

In the first three months of 2013 the percentage of IMs completing the MH Intake screening dropped to from 96% overall in 2012 to 85%. This change was brought to the attention of the joint medical and mental health QI committee. It was determined that change in compliance was due to the RNs increasing the number of “Pre-screenings” during high volume periods in booking. Many of the IMs who were “pre-screened” were booked and released before the RN could complete the full MH Intake.

Audits relevant to meeting timeframes for emergent, urgent, and referrals for MHEs were reviewed. Problems were identified relevant to meeting the specified timeframes. Dr. Harman indicated the issues with completing timely urgent and routine referrals included the following:

The untimely follow up of urgent (24 hour) and routine (72 hour) referrals are primarily due to court, lockdowns, visitation, commissary and before new CO’s were hired lack of movement [in addition to administrative staffing issues].

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Since the hiring of new CO’s and implementation of video visitation the noncompletions have been reduced on urgent and routine referrals.
May 2013 Recommendations for next 6 months:
1. Continue to audit responses to referrals from a timeframe perspective.
c. LCJ shall ensure that the mental health intake screening process includes inquiry regarding:
(1) past suicidal ideation and/or attempts; (2) current ideation, threat, or plan; (3) prior mental illness treatment or hospitalization; (4) recent significant loss, such as the death of a family member or close
friend; (5) history of suicidal behavior by family members and close friends; (6) suicide risk during any prior confinement; (7) any observations of the transporting officer, court, transferring agency,
or similar individuals regarding the inmate's potential suicide risk; (8) medication history; and (9) drug and alcohol withdrawal history.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (9/11)
May 2013 Assessment: The mental health intake screening process continues to include inquiry regarding the above reference elements, which is unchanged from the previous site assessment.
3. Assessment and Treatment.
a. LCJ shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, or who is otherwise referred for mental health services, receives a comprehensive mental status evaluation in a timely manner from a Qualified Mental Health Professional (immediate for emergent issues, within 24 hours of referral for an expedited comprehensive evaluation, or 72 hours of referral for a routine comprehensive evaluation). The comprehensive mental health evaluation shall include a recorded diagnosis section, including a s tandard five-Axis diagnosis from DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If Qualified Mental Health Staff find a serious mental illness, they shall refer the inmate for appropriate treatment. LCJ shall review available information regarding any diagnosis made by the inmate's community or hospital treatment provider, and shall account for the inmate's psychiatric history as a par t of the assessment. LCJ shall adequately document the comprehensive mental status evaluation in the inmate's medical record.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Refer to SA provision B.2.b. re: timeliness issues following a mental health referral. (95% of SRAs are completed by a QMHP with 86% being completed within the 24 hour requirement. 75% of urgent referrals completed within 24 hour requirement. 72% of routine referrals completed within 72 hour requirement).
The mental health evaluation form (MHE) in CT is utilized by QMHPs on a regular basis. A “stand alone” treatment plan is completed on every patient, which includes a standard five-Axis diagnosis from DSM-IV-TR, and entered into CT.
Line mental health staff reported that they do no routinely attempt to obtain mental health records from community providers. However, nursing staff in the intake area routinely attempt to verify medications reportedly prescribed to newly admitted inmates.
May 2013 Recommendations for next 6 months:
1. Improve compliance with completing referrals within the specified timeframes 2. Implement a process for mental health staff to routinely attempt to obtain mental health
records from community providers. 3. Develop a plan for training mental health staff re: DSM V and implement the plan.
b. LCJ shall ensure adequate and timely treatment for inmates whose assessments reveal serious mental illness, including timely and appropriate referrals for specialty care and regularly scheduled visits with Qualified Mental Health Professionals.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: My October 2012 report included the following:
[Re: the mental health unit on the fourth floor] group therapy continues to not occur. The reason cited is lack of correctional officer staffing to conduct movements… . Plans have been discussed to move the entire mental health unit to Z Pod, which is possible to accomplish within the next six months.
Based on information obtained from both custody and mental health staffs, the working relationships between the two staffs has improved but continues to be somewhat strained.
[Recommendations]: Expedite the reported plan re: moving of the mental health unit to Z pod. The correctional officers assigned to such a unit should receive special mental health training and be assigned to the unit for at least six months until unless they clearly demonstrate problems working on such a unit. Enhanced mental health staffing will be required in order to provide the necessary psychosocial rehabilitation treatment, which will be predominantly group and activity therapies.

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April 2013 update: 7 Group Therapy and Medication Education groups are being conducted Monday through Friday by the Psychiatric Nurse Practitioner, Clinical Supervisor and MHTs.
The increase in the new correctional officers has eliminated the movement issues related to the daily mental health clinic, individual and group sessions.
Cooperation between custody and the mental health department has reportedly improved due to a series of joint meetings with mental health, custody supervisors, DW Hogan and AW Ivetic.
The mental health treatment being provided to inmates with serious illness, especially on the fourth floor, is improved but remains inadequate related to mental health and correctional staffing allocations and physical plan problems.
May 2013 Recommendations for next 6 months:
1. Implement the reported plan re: moving of the mental health unit to Y (originally planned for Z Pod) pod.
2. Perform the mental health staffing plan as previously referenced.
c. LCJ shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: MH Staff received in-service trainings on the policy focusing upon MHE and Treatment Plans since the last site assessment. The Clinical Supervisor has established a weekly review of treatment plans and these are discussed in weekly supervision of QMHPs by the Clinical Supervisor.
A “stand alone” treatment plan is completed on every patient and entered into CT. Carl Alaimo, Psy.D. has met with the mental health department to coordinate focused training on treatment planning for SRAs and treatment plans resulting from MHEs.
I reviewed the draft comprehensive treatment plan form and made recommendations re: revisions in terms of goals, interventions and measurable outcomes.
May 2013 Recommendations for next 6 months: 1. Finalize the treatment plan form. 2. Training re: treatment plan implementation via Dr. Alaimo. d. LCJ shall provide for an inmate's reasonable privacy in mental health care, and maintain confidentiality of inmates' mental health status, subject to legitimate security concerns and emergency situations.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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May 2013 Assessment: Construction of new intake area is complete. The improvements are very beneficial.
“Privacy issues” have been addressed in the new booking area although some form of sound batt insulation is needed in the interview rooms due to significant sound proofing issues that currently exist.
Mental health staff has been provided a specific area to interview inmates in booking with complete access to CT.
A full-time Psychiatric Nurse Practitioner (PNP) was hired in November of 2012. The PNP conducts evaluations in private office with correctional officer posted outside the door.
May 2013 Recommendations for next 6 months:
Remedy the sound proofing issue.
e. LCJ shall provide adequate on-site psychiatric coverage for inmates' serious mental health needs and ensure that psychiatrists see such inmates in a timely manner.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: There were 183 inmates on the mental health caseload receiving psychotropic medications during May 6, 2013.
My April 2012 recommendations included the following: “Increase the psychiatric allocation to 1.0-1.5 FTE psychiatrists.” Since the October 2012 site assessment, the psychiatric allocation was increased from 16 hours of service by the psychiatrist by hiring a 40 hour per week psychiatric nurse practitioner. This alleviated the back log of inmates waiting to be evaluated. Initial psychiatric appointments are generally scheduled within 17 days of referral, which is a significant improvement from prior site assessments. However, the current PNP allocation does not permit follow-ups visits to be routinely scheduled and routine mental health sick call requests have a backlog of ~ 17 days.
The CT productivity report reveals PNP averages approximately 300 psychiatric encounters per month. Prior to hiring the PNP psychiatric encounters averaged 70-80 per month. Despite this improvement in productivity, the PNP/psychiatrist allocation is clearly not adequate. Due to budget constraints the psychiatrist’s hours were reduced from 16 per week to 3 hours of supervision per week. In early November 2012 the psychiatrist resigned. A psychiatrist is needed at the LCJ for several reasons that include the legal requirement that the PNP has a collaborative agreement with a psychiatrist. Unfortunately, another psychiatrist has not yet been hired. Feedback from some psychiatrists indicate the problem with securing psychiatric services

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may be due to the compensation package (3 hours per week @ $195 per hour) in the context of the risk of liability within LCJ.
May 2013 Recommendations for next 6 months:
1. A psychiatrist needs to be hired for supervision purposes of the PNP. 2. Increase the number of psychiatric hours at the LCJ. It is likely that 2.0 FTEs will be
needed, especially after the special mental health unit is opened.
f. LCJ shall ensure timely and appropriate therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate space for treatment, adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: See section B.3.b. Very little change is present as compared to the prior site assessment.
Refer to section B.3.j. for information relevant to access to inpatient psychiatric care.
Except for inmates on the fourth floor, the predominant treatment for inmates receiving mental health treatment is medication management and counseling, as needed, in contrast to being seen on a regular basis. Segregation inmates generally are not receiving counseling in a setting that allows for adequate sound privacy related to both physical plant issues and correctional officer staffing allocation issues.
Mental Health patients housed in B dayroom and G dayroom were reported to continue to have access outside the cell a minimum of 4 hours per day.
May 2013 Recommendations for next 6 months:
Recommendations are essentially unchanged from my April 2012 r eport which included the following:
As stated in B.3.b., inmates with the most serious symptoms of a mental illness are essentially locked in their cells [22-23] hours a day reportedly related to primarily physical plant issues. Such restrictions are not only non-therapeutic but are likely to make many of these inmates clinically worse. The current physical plant is not appropriate for many of these inmates with serious mental illnesses and alternative housing options needs to occur.
An outpatient level of mental health care needs to be more developed and implemented in contrast to the treatment just being seen by the psychiatrist on an untimely basis.

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g. LCJ shall ensure mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals in order to assess the serious mental health needs of inmates in segregation. Inmates with serious mental illness who are placed in segregation shall be immediately and regularly evaluated by a Q ualified Mental Health Professional to determine the inmate’s mental health status, which shall include an assessment of the potential effect of segregation on the inmate’s mental health. During these regular evaluations, LCJ shall evaluate whether continued segregation is appropriate for that inmate, considering the assessment of the Qualified Mental Health Professional, or whether the inmate would be appropriate for graduated alternatives.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: I observed the mental health rounding process in the segregation units during the morning of May 8, 2013, which was done in a competent manner.
A brief mental status exam is being utilized to screen and assess the needs of inmates with a mental illness in segregation although it is usually not completed within a timely basis as specified in this provision of this Settlement Agreement. Brief mental health assessments and MHEs are conducted outside of the segregation cells in a holding area. This affords some privacy from other inmates but is problematic due to staff traffic in the immediate area. The QMHP regularly uses the brief mental health assessment as part of the evaluation process.
The Clinical Supervisor assigned QMHP met with Sgt. Leto as well as other custody staff to improve working relationships and relevant discussions regarding the need for privacy, policy requirements and the necessity of transferring some segregated inmates to the 4th floor. When it is determined by the QMHP that an inmate’s disciplinary sanction might be mitigated by their mental illness a transfer is made to the 4th floor if appropriate. QI data indicates transfers to the 4th floor have happened without impediment from custody. However, not all inmates with a serious mental illness in segregation are receiving mental health assessments for potential mitigation purposes.
Audits indicate an average of 2 inmates per month require transfer from segregation to the 4th floor. The highest number was 5 in one month with some months zero transfers were required. Since January of 2012 no segregated inmates required a transfer to a psychiatric hospital to meet their needs. The majority of the transfers to the 4th floor were for medication and stabilization needs. Information was obtained from Sgt. Leto and Deputy Warden Gore re: the disciplinary hearing process. Although it was clear that a process exists for obtaining mental health input into the disciplinary, it was not a formal process and was not consistent with the above provision of the SA.

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QI studies indicate the average daily population for segregation is 24 inmates daily. During any given month the number of different inmates admitted to segregation housing averages 49 inmates. Of these 49 inmates an average of 7 have a diagnosis of mental illness and another 8 inmates have a diagnosis of a serious mental illness (SMI). The primary SMI diagnosis remains schizophrenia.
Weekly rounds are provided by the QMHP with an average of 40 monthly encounters. Of the 40 encounters 17 are those inmates with a diagnosis of mental illness and 23 inmates with a diagnosis of SMI.
Since May 2012 the same QMHP has been assigned to conduct weekly MH rounds in segregations.
May 2013 Recommendations for next 6 months:
A formal process needs to be developed and implemented concerning providing mental health input into the disciplinary process consistent with the above provision of the SA.
h. LCJ 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. Each clinician shall have ready access to a c urrent log listing any prescribed medication and dosages for inmates on psychotropic medications. In addition, inmate's files shall contain current and accurate information regarding any medication changes ordered in at least the past year.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: CT does not have the capacity to produce all of the elements of the above referenced log.
May 2013 Recommendations for next 6 months:
Develop other mechanisms for producing the above log information in a reasonable time efficient manner.
i. LCJ shall ensure that a Qualified Mental Health Professional conducts an in-person evaluation of an inmate prior to a medically-ordered seclusion or restraint, or as soon thereafter as possible. Patients placed in medicallyordered seclusion or restraints shall be evaluated on an on-going basis for physical and mental deterioration. Seclusion or restraint orders should include sufficient criteria for release.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE.

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May 2013 Assessment: The restraint chair policy has been finalized.
Correctional and medical staffs have reportedly been trained on the appropriate use of restraints.
From April through December 2012, there were 7 incidents of the use of the restraint chair with mental health caseload inmates. Audits have not been performed re: compliance with the restraint chair policy and procedure.
Review of the healthcare records of two inmates who required the use of clinical restraints indicated that the policy and procedure was not being followed with specific reference to the initial four hour face to face assessment. Other aspects of the policy and procedure also need to be audited on a concurrent basis or very shortly after the restraint episode is ended.
May 2013 Recommendations for next 6 months:
1. Re-train staff re: the restraint policy and procedure. 2. Train and privilege the RNs in the context of the policy, with a focus on the face to
face assessment. 3. Audit implementation of this policy.
j. LCJ shall ensure an adequate array of crisis services to appropriately manage the psychiatric emergencies that occur among inmates. Crisis services shall not be limited to administrative segregation or observation status. Inmates shall have access to appropriate licensed in-patient psychiatric care, when clinically appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: LCJ has improved relationship with many community agencies. Cooperative efforts between LCJ, Regional Mental health, Edgewater Systems for Balanced Living, Gary City Court and county courts have resulted in increased access to outside psychiatric services for inmates.
LCJ continues a cooperative working relationship with the services of Methodist Hospitals in Gary and Merrillville.
Regional Mental Health continues to serve LCJ by providing timely “gate keeper” functions for inmates requiring state hospitalizations. In addition, Regional Mental Health continues to provide 24/7 emergency services for inmates being released from LCJ who still need continued MH services. In 2012 a total of 17 involuntary commitments were made to the state hospital system. Much of this occurred the first 9 months of the year. In 2013 there have been 4 transfers to the psychiatric hospitals. Five inmates have transfers pending to psychiatric hospitals. Court orders for involuntary psychotropic medications were pending for five inmates.

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Various local courts, especially Gary City Court with Judge Deidre Monroe, have been instrumental in inmates receiving the medications necessary to stabilize their condition. The courts have been more open to “mandated medications” which has resulted in a reduction of the number of inmates requiring a transfer to inpatient psychiatric services. There were significant differences in the due process available to inmates in the context of nonemergency involuntary medications administration which depended on the court of jurisdiction (i.e., city vs. county).
Due to the continued efforts of the Clinical Supervisor, Robert Nagan, a cooperative relationship has been developed with Edgewater Systems for Balanced Living. In 2013 Edgewater agreed to transfer 2 LCJ inmates to two of their residential programs.
Since the last DOJ review LCJ has developed a working relationship with St. Margaret Mercy Hospital system.
May 2013 Recommendations for next 6 months:
1. Continue to foster the relationships with community mental health providers. 2. Finalize the policy and procedure for administration of involuntary medications on a
nonemergency basis.
4. Psychotherapeutic Medication Administration
a. LCJ shall ensure that psychotherapeutic medication administration is provided when appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 A ssessment: A QI study addressed issues related to refusal of medications, which subsequently resulted in a s ignificant decrease of refusals related to educational efforts by the PNP. QMHPs and MHTs routinely follow up in an attempt to increase medication compliance.
Audit results indicated that inmates are receiving prescribed medications within 24 hours of the medication being prescribed. Issues remain in the context of medication continuity when inmates are transferred from one housing unit to another.
Other QI audits need to address medication management issues such as continuity of medication issue, untimely expiration of prescriptions and discharge medications.
May 2013 Recommendations for next 6 months:
Continue to audit medication management issues. b. LCJ shall ensure that psychotropic medication orders are reviewed by a psychiatrist or physician on a r egular, timely basis for appropriateness or adjustment. L CJ shall ensure that changes to inmates' psychotropic medications are clinically justified and documented.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Psychiatric services increased from 16 hours to 40 hours per week with the hiring of the PNP. An average of 300 encounters per month has been recorded in the EMR.
QI report entitled “Faith Ornelas Caseload” tracks follow ups after initial psychiatric evaluations. Previously there was a large back log of inmates waiting for the initial psychiatric evaluation. All back logs have been caught up.
Information obtained from the PNP indicated that timely follow-up of inmates who are newly prescribed medications does not routinely occur unless they are housed on the 4th floor.
May 2013 Recommendations for next 6 months:
1. A psychiatrist needs to be hired for collaboration/supervision purposes. 2. The current allocation for a PNP/psychiatrist is not adequate to provide the
needed psychiatric services to inmates with a mental illness at the LCJ. It is likely that 2.0 FTE positions will be needed.
c. LCJ shall ensure timely implementation of physician orders for medication and laboratory tests. LCJ shall ensure inmates who are being treated with psychotropic medications are seen regularly by a ph ysician to monitor responses and potential reactions to those medications, including movement disorders, and provide treatment where appropriate.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Protocols are in the early phase of being developed re: laboratory testing and psychotropic medications. The PNP is not receiving the lab results in a timely manner related, apparently, due to MIS issues.
May 2013 Recommendations for next 6 months:
1. Correct the MIS issues so that the PNP is notified directly re: lab studies ordered by her.
2. Finalize the above protocols, implement it and perform QI studies re: the implementation.
C. SUICIDE PREVENTION: Settlement Agreement Part III Section C.
1. Suicide Prevention Policy.
a. LCJ shall develop policies and procedures to ensure the appropriate management of suicidal inmates, and establish a suicide prevention program in accordance with generally accepted correctional standards of care.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Suicide Prevention Policy updated 2.25.13 by Lindsay Hayes to change EMTs to RNs and 10 minute S.P. rounds to 15 minute checks.
New section in the policy entitled: “Release from Custody While on Suicide Precautions” addresses safety concerns for patients released from custody who are still in need of mental health services due to active suicidal ideation.
All other areas of policy and procedures remain the same.
100% of Mental Health Department completed the 2 hour suicide prevention annual in-service on 4.3.13.
See the findings of other section of this provision in the context of establishing a s uicide prevention program in accordance with generally accepted correctional standards of care.
May 2013 Recommendations for next 6 months:
1. As per the recommendations in the following sections of this report.
b. The suicide prevention policy shall include, at a minimum, the following provisions:
(1) an operational description of the requirements for both preservice and annual in-service training;
(2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (4/11)
May 2013 Assessment: The suicide prevention policy includes all of the above provisions.
c. LCJ shall ensure suicide prevention policies include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (10/12)
May 2013 Assessment: A recent audit demonstrated continued compliance with this provision in the context of supervision by the mental health staff.

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d. LCJ shall ensure security staff posts in all housing units are equipped with readily available, safely secured, suicide cut-down tools.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (4/11)
May 2013 Assessment: Sustained compliance remains based on audit results.
e. LCJ shall ensure that cells for suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, exposed bars, unshielded lighting or electrical sockets).
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
May 2013 A ssessment: Five cells in Section 4C were being retrofitted for suicide prevention during the latter part of the site visit. They had previously been used for suicide watch purposes.
f. LCJ shall document inmate suicide attempts at LCJ in an inmate's correctional record in the classification system, in order to ensure that intake staff will be aware of past suicide attempts if an inmate with a history of suicide attempts is readmitted to LCJ.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (10/12)
May 2013 Assessment: No change. The red pop up screen continues to work as designed.
2. Suicide Precautions.
a. LCJ shall ensure that suicide prevention procedures include provisions for constant direct supervision of actively suicidal inmates and close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks). LCJ shall ensure that correctional officers document their checks.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (10/12)
May 2013 Assessment: No change .
b. LCJ shall ensure that when staff initially place an inmate on Suicide Precautions, the inmate shall be searched and monitored with constant direct supervision until a Qualified Mental Health Professional conducts a suicide risk assessment, determines the degree of risk, and writes appropriate orders. Until such an assessment, inmates shall be placed in gowns recommended and approved for use with suicidal patients.

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OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: A March 22, 2013 QI assessment by Lindsay Hayes found issues with the quality of some of the SRAs performed.
May 2013 Recommendations for next 6 months:
Provide additional training and supervision re: the suicide risk assessments.
c. LCJ shall ensure that, at the time of placement on Suicide Precautions, Qualified 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 a Qualified Mental Health Professional, except under emergency circumstances.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: Little change from the previous site assessment in terms of decreasing property restrictions after the first 24 hour s of suicide watch. D ocumentation re: reasons for continued restrictions need to be improved.
May 2013 Recommendations for next 6 months:
1. Train staff re: this provision and re-audit.
d. LCJ shall ensure inmates on Suicide Precautions receive regular, adequate mental status examinations by Qualified Mental Health Staff. Qualified Mental Health Staff shall assess and interact with (not just observe) inmates on Suicide Precautions on a daily basis.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE (5/13)
May 2013 Assessment: The 3.22.13 audit by Lindsay Hayes demonstrated compliance with this provision.
e. LCJ shall ensure that inmates will only be removed from Suicide Precautions after approval by a Qualified Mental Health Professional, in consultation with a psychiatrist, after a suicide risk assessment indicates it is safe to do so. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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May 2013 Assessment: QI studies show compliance with the follow-up assessments.
Issues remain with the quality of the treatment plans.
May 2013 Recommendations for next 6 months:
1. Provide training re: treatment planning. 2. Audit all the elements of this provision.
3. Suicide Risk Assessments.
a. LCJ shall ensure that any inmate showing signs and symptoms of suicide is assessed by a Q ualified Mental Health Professional using an appropriate, formalized suicide risk assessment instrument within an appropriate time not to exceed 24 hours of the initiation of Suicide Precautions.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment: The audit by Mr. Hayes indicated that problems remain with the quality of the initial SRAs and, at times, the lack of an initial SRA.
May 2013 Recommendations for next 6 months:
1. Continue to train and monitor.
b. LCJ shall ensure that the risk assessment shall include the following and findings from the risk assessment shall be documented on both the assessment form and in the inmate’s medical record:
i. description of the antecedent events and precipitating factors; ii. suicidal indicators; iii. mental status examination; iv. previous psychiatric and suicide risk history; v. level of lethality; vi. current medication and diagnosis; and vii. recommendations or treatment plan.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (10/12)
May 2013 Assessment:
No change.

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4. Suicide Prevention Training.
a. LCJ shall review and, to the extent necessary, revise LCJ's suicide prevention training curriculum to include the following topics:
i. the suicide prevention policy as revised consistent with this Agreement;
ii. why facility environments may contribute to suicidal behavior; iii. potential predisposing factors to suicide; iv. high risk suicide periods; v. warning signs and symptoms of suicidal behavior; vi. observation techniques; vii. searches of inmates who are placed on Suicide Precautions; viii. case studies of recent suicides and serious suicide attempts; ix. mock demonstrations regarding the proper response to a s uicide
attempt; and x. the proper use of emergency equipment, including suicide cut-down
tools.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE (9/11)
May 2013 Assessment: No change. Sustained compliance achieved.
b. Within 12 months of the effective date of this Agreement, all LCJ staff members who work with inmates shall be trained on LCJ's suicide prevention program. Staff shall demonstrate competency in the verbal and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least annual training shall be provided.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE for initial training. (9/11); SUBSTANTIAL COMPLIANCE for annual training (5/13)
May 2013 Assessment:
The 2 hour annual Jail Suicide Prevention training was developed by Lindsay Hayes. Terry Harman, Mental Health Director trained 100% of the Mental Health Department on 4.3.13. The Director will conduct the annual trainings for other Jail staff according to the training department schedule. Eight hour initial suicide prevention training was conducted for new correctional officers 10.25.12, 11.8.12, 12.20.12, 1.11.13, 3.7.13. Two hour annual suicide prevention training was conducted for mental health department 100% 4.3.13
May 2013 Recommendations for next 6 months:
Continue to monitor compliance with annual training requirements.

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D. FIRE SAFETY: Settlement Agreement Part III Section D.
1. Fire Safety.
a. LCJ shall develop and implement a c omprehensive fire safety program and ensure compliance is appropriately documented. The initial fire safety plan shall be approved by the State Fire Marshal or the Crown Point Fire Chief or Inspector. T he fire safety plan shall be reviewed thereafter by the Marshal, Fire Chief or Inspector at least every two years, or within six months of any revisions to the plan, whichever is sooner.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
Based upon my review of fire safety related documents, staff interviews and personal observations, I found that LCJ continues to make considerable progress in the development and implementation of a comprehensive fire safety program. The written comprehensive fire safety program has been developed and implemented that includes: a fire safety policy and procedure; a location guide; fire safety forms; a training schedule; a training component; a written test; a practical test; and information regarding fire extinguisher maintenance. The fire safety plan also includes an inspection process and record keeping requirements. The full-time Fire Safety Officer for LCJ has substantial training and experience in fire safety matters. The initial fire safety plan was reviewed and approved by the Crown Point Fire Inspector on March 29, 2012. The fire safety plan will need to be reviewed by the Crown Point Fire Inspector in March 2014 or sooner if any revisions are made to the fire safety plan.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County Jail staff should continue to include the Crown Point Fire Department crew in some of their evacuation drills as recommended by the Fire Inspector in his March 29, 2012 letter to Lake County. The Crown Point Fire Captain participated in the December 2012 f ire drill that also included the key inspection process which is also commendable.
2. Lake County staff should continue to maintain the fire safety standards they have achieved.
b. LCJ shall ensure that comprehensive fire drills are conducted every three months on each shift. LCJ shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
Based upon my review of documents and interviews with staff and inmates, I found that the facility has developed a comprehensive fire drill program for the jail. Records reflect that LCJ staff are conducting fire drills on all shifts and a Quality Assurance reporting system was developed for monitoring fire drills. LCJ staff are also monitoring the start to finish times of the fire drills as well as evacuation time frames. In April 2012 a full-time Fire Safety Officer was appointed and continues to oversee the implementation of the fire safety program for LCJ. The Fire Safety Officer is charged with the responsibility for ensuring that the fire drill schedule is fully implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Lake County staff need to ensure that they stay on schedule with respect to their fire drill program and to analyze the evacuation time frames and data to make sure inmates are promptly evacuated from their housing units in case of a fire or smoke situation.
2. During the next compliance visit I will be reviewing fire drill monitoring reports and evacuation procedures.
c. LCJ shall ensure that LCJ has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
All of the housing areas and other areas of the facility are equipped with fire and smoke alarm systems. Maintenance and storage areas are equipped with fire sprinklers as well as food service areas. Facility staff continue to ensure that AED’s and SCBA’s are present in strategic areas of the jail and are being inspected. There were fire extinguishers available in all areas of the jail. A Quality Assurance tracking system has been developed for ensuring this provision of the SA continues to be maintained.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to adequately maintain their fire and life safety equipment as required by this paragraph of the SA.
d. LCJ shall ensure that all fire and life safety equipment is properly maintained and routinely inspected.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE

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ASSESSMENT:
Based upon my review of documents and staff interviews, I found that LCJ staff have continued to conduct inspections of all fire and life safety equipment on a monthly basis as well as ensuring it is properly maintained. The LCJ Fire Safety Officer continues to serve on a full-time basis and oversees the fire safety program. The duties and responsibilities of the Fire Safety Officer, including the provisions of this paragraph of the SA were approved by the Sheriff on May 2, 2012. For the purposes of sustainability LCJ staff have developed a Quality Assurance monitoring system with performance measures.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to conduct inspections of all fire and life safety equipment and ensure it continues to be properly maintained.
e. LCJ shall ensure that emergency keys are appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately trained in use of the emergency keys.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
Facility staff continue to work in developing and implementing a system for emergency key management. The emergency keys have been inventoried. Emergency keys have been placed in all facility control rooms and the radio room. The number of emergency keys assigned to each key ring is manageable. An emergency set of keys has been placed in the Sheriff’s Communication Center which is located outside of the Jail. A system of identifying emergency keys by touch has not yet been developed and implemented. LCJ staff reported that the Crown Point Fire Inspector determined that facility conditions do not warrant key-identification by touch; however, this requirement is specifically addressed in the SA and in the Life Safety Code Handbook and cannot be minimized. (See Life Safety Code Handbook 2009 Chapter 23.7.5) During the inspection I discussed several options with LCJ staff for coming into compliance with this provision of the SA. LCJ staff have developed and implemented a Key Control policy and a key inspection program. A baseline audit was conducted in 2012 and additional keys were purchased. LCJ staff developed an audit process for the key control program and it appears to be working well. LCJ staff also developed a “chit system” for the control and accountability of facility keys and it also appears to be working well. Staff are knowledgeable of the emergency key process as my inspection revealed. Facility staff are being trained in the use of the emergency keys and has been incorporated into the fire safety training program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff need to develop a system of identifying emergency keys by touch. 2. The overall key control program needs to continue to be audited on a frequent basis
by the Facility Fire Safety Officer and the Fire Safety Compliance Inspector due to

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the fire safety implications the key control program has in the overall fire safety program. 3. Jail staff need to continue to be trained in the use of emergency keys as part of the pre-service and in-service staff training program.
f. LCJ shall ensure that staff are able to manually unlock all doors (without use of the manual override in the event of an emergency in which the manual override is broken), including in the event of a power outage or smoke buildup where visual examination of keys is generally impossible. LCJ shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. LCJ shall conduct regular security inspections and provide ongoing maintenance to security devices such as door locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
During the inspection, jail staff continue to be knowledgeable on how the manual door unlocking system operates. During the tour I inspected and tested several locking mechanisms and doors and all were operable. LCJ staff have developed and implemented a door inspection policy. Staff continue conducting proficiency audits of floor officers in conjunction with fire safety drills and the process has been formalized and audits are being conducted on all shifts. The fire safety staff have developed a “Manual Unlocking Mechanisms Quarterly Test” schedule which is very helpful in tracking this requirement. It appears that the Fire Safety Officer is the primary staff member who coordinates this effort; however, the evening and night shift security supervisors could also be conducting these types of random audits and report the findings to the Fire Safety Officer as well as generating maintenance work orders on any needed repairs that may be identified. The reports generated by the Fire Safety Officer regarding these types of inspections are good and are helpful in identifying discrepancies in the system. Whenever a maintenance related discrepancy is identified, it is reported to the Maintenance Department via a work order.
RECOMMENDATION FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to conduct formal random audits for testing staff proficiency in performing manual unlocking of all doors with the use of manual override system. The results of these audits should continue to be documented.
2. Security supervisors in the evening and night shifts can help supplement the random audits and report the findings to the Fire Safety Officer and Maintenance Department.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR NEXT TOUR:
I would like to continuing reviewing documents that demonstrate the results of the inspections/audits that were conducted for the emergency unlocking system and staff response as well as the follow-up maintenance repairs.

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g. LCJ shall implement competency-based testing for staff regarding fire and emergency procedures.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
With the assistance of the Crown Point Fire Inspector, LCJ staff have developed a training curriculum for fire and emergency procedures. Staff have started to receive training in fire and emergency procedures. LCJ staff reported that approximately 96% of the required staff have been trained on this requirement. There were training sessions conducted in July 2012 and October 2012 and has become part of the pre-service and in-service staff training program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should ensure to provide competency-based testing for staff regarding fire and emergency procedures.
h. LCJ shall ensure that fire safety officers are trained in fire safety and have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ has a full-time staff member to serve as the facility Fire Safety Officer. The duties and responsibilities for this position were articulated in writing by the Sheriff on May 2, 2012. The duties and responsibilities for this position are included as part of the fire safety plan. The person appointed for this position has an extensive background in fire safety and emergency management. She is a certified fire fighter and has attended numerous trainings in emergency management. The Fire Safety Officer continues to interact with the local fire department and the DOJSA in seeking assistance and guidance for the facility fire safety program.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The LCJ Fire Safety Officer should continue to avail herself of available training on fire safety, basic housekeeping, emergency management, the basic applicable codes, the use of fire extinguishers and other emergency equipment.

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E. SANITATION AND ENVIRONMENTAL CONDITIONS.
1. Sanitation and Maintenance of Facilities.
a. LCJ shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas. Such policies should include oversight and supervision, including meaningful inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
LCJ continues to implement their housekeeping and sanitation plans. Monthly inspection forms were developed and they are in the process of automating the inspection process. Additional equipment and supplies are being distributed to the housing units. Three more staff members were added to the sanitation program as well as increasing the inmate manpower. A sanitation work crew of staff and inmates has been assigned to the booking area and sanitation continues to improve. At this point, staff need to more closely supervise and properly train inmate workers on the proper cleaning and sanitizing of the booking cells and plumbing fixtures. The booking area has undergone significant upgrades to the floor, shower areas ventilation system which is commendable. Sanitation staff have also continued to be involved in replacing shower curtains. Housing unit and booking cell vents continue to improve in terms of keeping them free of blockage by inmates, but more work needs to continue in this area. The showers and general areas of the medical department were much cleaner than on previous inspections. The showers in the medical area were refurbished and they are much improved.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to implement their written housekeeping and sanitation plans for the jail as well fully implementing the inspection program.
2. LCJ staff must ensure that the housing unit inmate workers and inmate work crews are adequately supervised and instructed on the proper cleaning and sanitizing procedures.
3. LCJ staff need to continue to provide additional emphasis to the overall housekeeping program in the housing units, medical area and booking.
b. LCJ shall implement a preventive maintenance plan to respond to routine and emergency maintenance needs, including ensuring that shower, toilet, and sink units are adequately maintained and installed.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
LCJ staff continues to make strides in refurbishing the physical plant and making needed repairs to the plumbing system, including the shower areas and cell plumbing. However, there are still many plumbing problems to overcome. LCJ staff reported that a major plumbing project for refurbishing the plumbing system in the housing units will commence in June 2013. During the tour, I did not observe roof leaks. There are continuous painting projects underway. The lighting system was in a good state of repair. LCJ staff developed an automated system for the tracking of facility work orders and it appears to be working well. The automated system also includes a preventative maintenance component. LCJ staff are in the process of developing an inventory of spare parts.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to conduct needed repairs to the physical plant and plumbing system.
2. LCJ staff should continue to implement their written preventative maintenance plan including the schedules for preventative maintenance inspections and repairs, staff assignments that are responsible for inspection and repairs and develop an inventory of regularly needed spare parts and plumbing fixtures.
3. The above requirements should continue be addressed in a facility policy and procedure and should be revised as programs are implemented to the system.
c. LCJ shall ensure adequate ventilation throughout LCJ to ensure that inmates receive an adequate supply of airflow and reasonable levels of heating and cooling. LCJ shall review and assess compliance with this requirement at least twice annually.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During the inspection I observed that several inmate cells had the air vents covered with materials thus obstructing air flow. With the acquisition of the new floor officers it is expected that this area will continue to improve due to more officer presence in the housing units. I also observed that in many of the housing unit dayroom areas the return air flow vents were much cleaner and free of lint and debris and they are being better maintained. LCJ staff also hired an outside contractor to help clean the difficult to reach vents and internally address the vents that can be reached without additional equipment. In order to maintain the ventilation system clean, it requires the continued and intense cleaning and staff supervision over the inmate crews that are performing these types of tasks. The facility continues to do a good job with the assistance of Johnson Controls in monitoring the airflow and heating and cooling system. Facility staff are able to readily monitor these systems through the use of an automated tracking and reporting system.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Staff should continue with their efforts to ensure that cell vents are not covered by the inmates. This can be partly accomplished by conducting daily cell sanitation inspections. However, there must also be sufficient numbers of detention officers available in the housing units in order to accomplish these tasks.
2. Maintenance and the environmental vendor staff should continue to keep records of temperature readings of the housing units and other areas of the jail.
3. The return air vents in the housing unit dayrooms should continue to be regularly cleaned and made free of debris as part of the on-going and preventative maintenance program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
During the next tour, I will be reviewing LCJ efforts in providing enhanced supervision within the inmate housing units and over the inmate work crews.
d. LCJ shall ensure adequate lighting in all inmate housing and work areas and cover all light switches with exposed wires.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During this inspection I did not detect problems with the lighting system. LCJ staff continue to work diligently on making repairs to the lighting system and replacing light bulbs and fixtures. I did not detect any exposed wiring during my inspection. Lighting in inmate cells and dayrooms was adequate.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to maintain the lighting and electrical system in a good state of repair.
e. LCJ shall ensure adequate pest control throughout the housing units, medical units, and food storage areas.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection of inmate housing units, program areas, the food service department, the medical area and general areas of the Jail, I did not detect a problem with pest control. LCJ continues to maintain pest control services that provides for regular inspections and pest control.

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There were, however inmate complaints of ant infestation in some of the housing units in the Old Jail that were valid. The issue was brought up to LCJ staff and the records reflect that extermination services continue to be provided, but there are occasions when the exterminator services need to be directed to a specific problem.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue with their pest control program.
f. LCJ shall ensure that all inmates have access to needed hygiene supplies.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I did not observe a problem in this area. Inmates had in their possession needed hygiene supplies, both at intake and in the housing units. LCJ staff continue to maintain a significant amount of hygiene supplies in storage areas.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Continue to issue inmate hygiene supplies at intake to inmates and as needed. 2. Include in the revised Inmate Handbook hygiene issue quantities and frequency of
issue.
g. LCJ shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials. LCJ shall ensure that any inmate or staff utilized to clean a bi ohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
LCJ staff continue to revise their policies and procedures to address this area of operation. I observed during this inspection that spill kits continue to be made available in various areas of the facility. I also observed in the medical area (exam rooms) that biohazard containers with enclosures were available and the containers were properly covered with the lids. LCJ staff provide supervision of inmates when they are cleaning up biohazard spills.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to maintain biohazard program.
h. LCJ shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
The facility continues to use universal cleaning chemicals for cleaning biohazard spills as well as a bleach solution.
RECOMMENDATIONS FOR THE NEXT VISIT:
1. LCJ supervisory staff should continue to ensure that staff and inmates that clean biohazard spills follow the recommended instructions of the chemicals used for the cleanup.
i. LCJ shall inspect and replace as often as needed all frayed and cracked mattresses. LCJ shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. LCJ shall ensure that mattresses are properly sanitized between uses.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the inspection I did not detect any frayed or cracked mattress. There continues to be ample supplies of inmate mattresses in storage for replenishment purposes. Inmates are assigned to clean mattresses between uses. Staff and inmates continue to use sanitation chemicals in accordance with the sanitizing chemical instructions. LCJ staff continue to provide written directives to the trustees and to all inmates as to the proper method of cleaning and sanitizing of mattresses. I also observed numerous new mattresses that are scheduled to replace old ones or those are not usable.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ supervisors should continue to train and instruct staff and inmates that are responsible for sanitizing mattresses on the proper use of the sanitizing chemicals. Supervisory staff should continue to inspect and review the mattresses sanitization process and ensure it is done correctly.

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j. LCJ shall ensure adequate numbers of staff to perform housekeeping duties.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
During my previous inspection LCJ had two full-time and one part-time sanitation officers; however, during this inspection, LCJ staff have increased the sanitation work force to six staff members. These officers continue to provide cleaning materials to inmates and to some extent they also supervise trustee workers. However, inmate workers within the housing units continue to receive little, if any, instruction and supervision for their cleaning duties on a daily basis. I found that sanitation in the housing units has improved from previous tour, but not significantly; however, the new sanitation officers have only recently been assigned. The bigger problem continues to be the general lack of supervision of inmates in the housing units. For example, I continue to observe only one floor officer trying to provide supervision to inmates in eight pods or two housing units in the new part of the jail, identical to previous finding. In the old part of the jail, I observed one officer trying to provide supervision of inmates in three to six living units (pods). It is unrealistic to expect that one officer can perform all the duties required of a floor officer and be able to perform them in a qualitative manner. I also continue to observe that officers do not normally enter the actual inmate living areas, but rather patrol the outside of the dayrooms and the catwalks. If inmates are out of their cells, the officer does not go into the actual living area. There are simply an inadequate number of detention officers deployed into the housing units to properly supervise inmates and in particular, for supervising inmates that are performing housekeeping duties.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to closely examine their correctional officer staffing levels and deployment practicesand move towards providing direct inmate supervision in the inmate housing units in order to better supervise inmates and the housekeeping and sanitation program.
ADDITIONAL INSTRUCTIONS/DOCUMENTS FOR THE NEXT TOUR:
It is expected that LCJ officials continue to work in increasing correctional officer presence in the housing units.
2. Sanitary Laundry Procedures.
a. LCJ shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
LCJ has implemented appropriate procedures for the laundry to protect inmates from risk of exposure to communicable disease. As I have reported in my previous reports, this area of operation also has staffing implications; however, the issue has been addressed by LCJ by adding two more laundry officers to help perform laundry requirements. LCJ officials have implemented a twice weekly laundry exchange program for both the female population and male population which is commendable. During the tour I observed laundry officers performing this additional duties. I also reviewed the updated laundry schedule and interviewed inmates who further confirmed these positive changes.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should ensure that they continue to implement their revised laundry schedule.
b. LCJ shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards (e.g., at least twice per week), and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
Based upon my observations, LCJ officials continue to maintain a substantial amount of inmate clothing, bedding and towels in order to satisfy this requirement of the SA. Two additional officers were added to the laundry operation to ensure that the provisions of this paragraph are being met. LCJ officials revised their laundry schedule in order to allow both male and female inmates are provided adequate clean clothing, underclothing and bedding at least twice per week.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to maintain this level of staff assigned to laundry services in order to continue to implement the revised laundry schedule.
c. LCJ shall train staff and educate inmates regarding laundry sanitation policies.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
As I reported in my previous reports, it appears that a private vendor has continued to provide training to laundry staff. Security staff are provided training on the provisions of the SA as it relates to laundry issues. However, a system has not yet been developed and implemented for educating inmates regarding laundry sanitation policies. The Inmate Handbook could be used as one avenue for educating inmates on laundry sanitation policies; however, formal revisions to the Inmate Handbook are still pending.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should be revised, finalized and include the expectations of inmates regarding laundry sanitation policies.
d. LCJ shall ensure that laundry delivery procedures protect inmates from exposure to communicable diseases by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ staff have developed practices that protects inmates from exposure to communicable diseases. I did not conduct a visit to the laundry during this tour, but staff reported that there have been no changes to the operation with the exceptions of adding two more laundry staff members and implementing the revised laundry schedule.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to provide instructions and oversight to staff and inmates on t he proper use of sanitizing chemicals and on c ross-contamination precautions.
2. LCJ staff should continue to maintain Material Safety Data Sheets in strategic areas of the jail where chemical are used and maintained.
e. LCJ shall require inmates to provide all clothing and linens for LCJ laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
The Inmate Handbook has still not been revised to include provisions on prohibiting inmates from washing and drying laundry outside the formal procedures. During this tour, I did not observe inmates washing undergarments, clothing and towels in the sinks, showers or toilets. LCJ staff continue to provide laundry exchange twice per week for the female population and have now also included the male population.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The Inmate Handbook should contain a provision prohibiting inmates from washing and drying laundry outside the formal procedures.
3. Food Service.
a. LCJ shall ensure that food service at LCJ is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures, and adequate meals are provided.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
From my observations and interviews with staff and inmates, I found that adequate meals continue to be provided. Meals are prepared in a safe and hygienic manner. LCJ food service staff continue to make improvements in the area of food temperatures. Temperature readings of meals are taken and recorded. These temperatures are satisfactory. Food carts continue to be delivered to the housing units in a more prompt manner which has immensely helped in maintaining proper food temperatures at serving time. Once the carts are delivered to the housing units I observed that the meals were promptly provided to the inmates.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. Supervisory staff should continue to monitor food service operations and ensure that food service staff obtain and document food temperatures.
2. Management staff and food service staff need to ensure that meals continue to be delivered and provided promptly to inmates so that problems are not encountered with food temperatures.
b. LCJ shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE

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ASSESSMENT:
During the inspection I met with food service staff and the dietician as well as conducting an inspection of the kitchen. Many improvements continue to be made in this area. For example, the dumpsters are still being cleaned on a weekly basis, food service equipment is maintained in good working order, among many other improvements. The dietician has continued to train staff as well as inmates on food service operations, the safe handling procedures and on appropriate sanitation. Records of these trainings are maintained. Material Safety Data Sheets continue to be made available in the kitchen.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to maintain their training records for food service staff and document all training provided, including food service staff orientations. C opies of these staff training sessions should be provided to the LCJ Training Coordinator.
c. LCJ shall ensure that kitchen(s) are staffed with a sufficient number of appropriately supervised and trained personnel.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
The food service department continues to be staffed with nine food service workers. The food service operation continues to be supplemented with inmate workers. The number of staff assigned to the kitchen appears to be sufficient; however, any reduction on the current staffing levels could have negative implications on the food service operation.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to maintain at the very least, the current food service staff complement.
d. LCJ shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
During the tour, I found that dishes and utensils, food preparation and storage areas continue to be clean and sanitary. I also noted that the food service delivery carts and food tray storage carts continue to be appropriately cleaned and sanitized.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the daily, weekly and monthly sanitation inspection program continues to be part of the food service system.
e. LCJ shall check and record, on a r egular basis, the temperatures in the refrigerators, coolers, walk-inrefrigerators, the dishwasher water, and all other kitchen equipment with temperature monitors to ensure proper maintenance of food service equipment.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ staff have developed and continue to maintain a system for checking and recording temperatures of the refrigerators, coolers, walk-in refrigerators and the dishwasher. LCJ staff continue to maintain records of these checks.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
It is my recommendation that temperatures of all refrigerators, coolers, walk-in refrigerators and the dishwasher water continue to be checked and recorded. This will allow food service staff to detect a temperature problem promptly so it can be corrected.
F. QUALITY IMPROVEMENT PROGRAM: Settlement Agreement Part III Section F.
1. LCJ shall develop and implement written quality management policies and procedures to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreement, as applicable.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment:
Policy and Procedure completed via work group consisting of Corrections and Medical-Mental Health staff working under the directive of the Sheriff’s March 2010 procedure for policy development
Recommendations for next 6 months: Continue to increase the number and scope of the QI studies with particular reference to relevant Settlement Agreement provisions. Please send me an electronic version of Policy 16.01.07 (Continuous Quality Improvement Program).

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2. LCJ shall develop and implement policies to address and correct deficiencies that are uncovered during the course of quality management activities, including monitoring corrective actions over time to ensure sustained resolution.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment:
LCJ has begun performing QA studies as a component of the evolving QI process.
Recommendations for next 6 months: Continue to increase the number and scope of the QI studies with particular reference to relevant Settlement Agreement provisions.
3. LCJ shall institute a Quality Improvement Committee and ensure that such committee meets on a monthly basis and that this committee includes representatives from medical, mental health, and custody staff.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment:
The Mental Health Department had established separate Mental Health Quality reports which are submitted monthly to Ken Ray and to the Medical-Mental Health Quality Improvement Committee. MH has monthly QI meeting that began 10/14/12.
The mental health QI results are evaluated by the consultant Ken Ray monthly and by the Medical Mental Health Committee Monthly. Dr Alaimo has been hired to work as a mental health consultant for QI purposes
MH developed the following QI reports 1) Segregation 2) Suicide Precautions MHE referrals from booking 3) S.P. Compliance (all referral sources) 4) SRA MHE completion compliance 5) CT report PNP encounters in development
Recommendations for next 6 months: Continue to increase the number and scope of the QI studies with particular reference to relevant Settlement Agreement provisions. Begin some QI studies in contrast to QA audits.
4. Quality management programs related to medical and mental health care will utilize performance measurements to assess quality of care and timely access to care with quantitative and qualitative data analysis and trending over time and specifically shall address: a. the effectiveness of the intake assessment, referral, and sick call process; b. the management and utilization of psychotropic medications; c. suicide prevention, including assessment of suicide risk, review and tracking of suicide attempts, monitoring of inmates on suicide observations or precautions;

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d. the appropriateness of physical plant facilities such as safe cells for management of at risk inmates, and follow-up and treatment for those who may have engaged in suicidal or self-harm activities;
e. the appropriateness of treatment planning and treatment interventions for inmates in the mental health program;
f. discharge planning for the effective management and continuity of care for inmates leaving the system; and
g. the quality of medical records and other documentation.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
May 2013 Assessment:
As previously referenced, a QI policy has been developed and QI activities initiated.
Recommendations for next 6 m onths: Continue to use the QI process to address the above performance measures.
G. PROTECTION FROM HARM: Settlement Agreement Part III Section G.
5. Use of Force by Staff.
a. LCJ shall develop and maintain comprehensive and contemporary policies and procedures surrounding the use of force and with particular emphasis regarding permissible and impermissible use of force.
OVERALL COMPLIANCE RATING: SUSTAINED COMPLIANCE
ASSESSMENT:
LCJ staff have developed and are maintaining comprehensive and contemporary policies and procedures surrounding the use of force and emphasizes permissible and impermissible use of force. The revised Use of Force policy was signed by the Sheriff on September 14, 2011. T he Use of Force policy continues to be updated as changes to the operation occur.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The finalized policy concerning the Use of Force should continue to be implemented.
b. LCJ shall address the following impermissible uses of force in its use of force policy and in the pre-service and in-service training programs for correctional officers and supervisors: (1) use of force as an initial response to verbal insults or inmate threats;

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(2) use of force as a response to inmates’ failure to follow instructions where there is no immediate threat to the safety of the institution, inmates, or staff, unless LCJ has attempted a h ierarchy of nonphysical alternatives that are documented;

(3) use of force as punishment or retaliation;

(4) striking, hitting, or punching a restrained inmate;

(5) use of force against an inmate after the inmate has ceased to offer resistance and is under control;

(6) use of choke holds on an inmate; and

(7) use of unnecessary or excessive force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

ASSESSMENT:

The final Use of Force Policy and Procedure contains the provisions of paragraph b. and subparagraphs 1-7 of the SA.

The Use of Force pre-service and in-service training program on the Use of Force Policy and Procedure has been initiated. LCJ has provided training on the Use of Force policy to six instructors. Approximately 97% of the correctional officers have received training on the Use of Force policy. Training on the Use of Force policy is now part of the pre-service and in-service staff training program. LCJ staff, with the help of their consultants, is in the process of developing an additional use of force training program for the supervisors. LCJ staff are working diligently on implementing the revised use of force program, but it will take some time to fully train and retrain all LCJ staff on t his new program. T raining for supervisors was schedule for June 2013 i n collaboration with the FBI; however, due to budget constraints the training has not occurred.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

LCJ officials need to continue to train correctional staff on t he Use of Force

policy.

2.

LCJ staff need to fully develop and implement the supervisor use of training

program.

c. LCJ shall develop and implement a pol icy to ensure that staff adequately and promptly report all uses of force.

OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE

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ASSESSMENT:
The revised Use of Force Policy and Procedure has been developed and finalized. The policy contains this provision of the SA. LCJ staff have commenced the process of providing training on the Use of Force policy to staff as noted previously above. Monitoring of the use of force reporting is conducted by the Staff Training Division and the Deputy Warden of Security. LCJ staff have developed a use of force tracking system (data tracker) which shows signs of effectiveness. W hen fully implemented, the system should be capable of accounting for each and every use of force, both reported and unreported. S ampling is on-going and is starting to provide useful and meaningful data. Also, a use of force review board has been developed and implemented which also contributes positively to this requirement.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ officials should continue to refine their process of monitoring this requirement of the SA internally and ensure that all use of force information is entered into the use of force database and that it is accurate and complete. LCJ staff should continue to verify that the use of force information is valid and verified.
2. LCJ staff should continue to qualitatively track, review and analyze use of force incidents for conformance with the SA.
3. LCJ staff should also continue to implement tracking system for all use of force incidents in order to be able to conduct comparative reviews of the program.
d. LCJ shall ensure that use of force reports will:
(1) be written in specific terms in order to capture the details of the incident;
(2) contain an accurate account of the events leading to the use of force incident;
(3) include a description of the weapon or instrument(s) of restraint, if any, and the manner in which it was used;
(4) be accompanied with the inmate disciplinary report that prompted the use of force incident, if applicable;
(5) state the nature and extent of injuries sustained both by the inmate and staff member;
(6) contain the date and time medical attention was actually provided;
(7) describe, in factual terms, the type and amount of force used and precise actions taken in a par ticular incident and avoid use of “boiler plate” descriptions for describing force, such as, “inmate

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taken to the ground with the force that was necessary;” and
(8) note whether a use of force was videotaped. If the use of force is not videotaped, the reporting correctional officer and supervisor will provide an explanation as to why it was not videotaped.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the elements of this provision of the SA including sub-paragraphs d. 1 -8. T he revised Use of Force Policy and Procedure has been approved and signed and implementation has commenced. T he Use of Force tracking system includes these requirements of the SA. However, the revised Use of Force report is still under development.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should continue to be implemented. LCJ staff should be conducting qualitative reviews of use of force reports to ensure conformance with the SA and the Use of Force Policy and Procedure.
2. I would also recommend that a new use of force report form be developed and implemented that includes all the elements of this provisions of the SA.
e. LCJ shall require prompt administrative review of use of force reports. Such reviews shall include case-by-case review of individual incidents of use of force as well as more systemic review in order to identify patterns of incidents. LCJ shall incorporate such information into quality management practices and take necessary corrective action.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. LCJ staff have commenced the process of training staff on the revised Use of Force policy. As reported earlier in this report, most of the correctional officers have already received training on the new Use of Force policy, but a separate use of force training component is being developed for supervisors that also needs to be fully implemented. A Use of Force Team was developed and implemented for reviewing use of force incidents primarily involving mentally ill inmates and it is showing signs of effectiveness.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should continue to be implemented and continue to train security staff and supervisors on i t as part of the pre-service and in-service training program.
2. Continue to further develop the Use of Force Review Team and consider expanding it to review all significant uses of force.
3. During my next review I will be reviewing use of force reports and the review process of use of force incidents.
f. LCJ shall ensure that Qualified Medical Staff request that inmates sign arelease of medical records for the limited purpose of administrative and investigative review of any incident involving an inmate injury. Q ualified Medical Staff will document the request and the inmate’s response. L CJ will ensure that inmates receive adequate medical care regardless of whether they consent to release their medical records.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
This provision of the SA is addressed in the revised Use of Force Policy and Procedure. LCJ staff and their consultants are working with Dr. Ron Shansky on ensuring that these requirements of the SA are met and are also addressed in medical policy and procedure. LCJ staff reported that this task remains under development.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the medical policies and procedures be developed and finalized and include these provisions of the SA and that both security and medical staff start receiving training on them.
g. LCJ shall ensure that management review of use of force reports and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical documentation of inmate injuries as reported by Qualified Medical Staff, including documentation surrounding the initial medical encounter, an anatomical drawing that depicts the areas of sustained injury, and information regarding any further medical care.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policies and Procedures. RJS consulting staff are working with the medical staff in ensuring that the

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medical policies and procedures address these provisions of the SA as well. LCJ staff reported that this task remains under development.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ Staff should continue with the implementation the revised Use of Force Policy and Procedure.
2. The medical policies and procedures should be developed and implemented and should contain the provisions of this paragraph of the SA.
h. LCJ shall establish criteria that trigger referral for use of force investigations, including but not limited to, injuries that are extensive or serious; injuries involving fractures or head trauma; injuries of a suspicious nature (including black eyes, broken teeth, injuries to the genitals, etc.); injuries that require treatment at outside hospitals; and reports of events by staff and inmates that are inconsistent.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. A s addressed previously in this report, considerable staff training has already been conducted regarding this provision paragraph of the SA. However, all staff need to be trained on it as part of the pre-service and annual in-service staff training program as well as developing and implementing the supervisor use of force training. LCJ staff with the guidance of the DOJSA Coordinator have developed a Use of Force Tracker that management staff use to identify trigger criteria for review and follow-up of investigations. The Deputy Warden can also make referrals to the investigations unit for reviewing questionable uses of force. The Sheriff is also actively involved in the process by obtaining the services of a third party to review questionable uses of force and has shown signs of effectiveness. D uring the inspection I also observed a Use of Force Review Team and was very impressed by their sincere commitment to the process.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ staff should continue to train all correctional staff on the revised Use of Force Policy and Procedure.
2. LCJ staff should continue to implement the positive changes that were made to the use of force program as described above.
i. LCJ shall develop and implement a s ystem to track all incidents of use of force that, at a minimum, includes the following information:
(1) a tracking number; (2) the inmate(s) name;

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(3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) if medical care is provided; (8) primary and secondary staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.

OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

ASSESSMENT:

These provisions of this paragraph of the SA have been incorporated into the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved, signed and partially implemented. The system to track all incidents of use of force has been developed and implemented requirements of this paragraph of the SA. RJS Consultants should continue to provide guidance in this critical area of the use of force program.

RECOMMENDATIONS FOR THE NEXT 6 MONTHS:

1.

The revised Use of Force Policy and Procedure should continue to be

implemented.

2.

The system for tracking all incidents of use of force should continue to be

implemented and adjusted as needed.

j. LCJ shall ensure that as part of a u se of force incident package, security supervisors shall ensure that photographs are taken of any and all reported injuries sustained by inmates and staff promptly following a u se of force incident. T he photographs will become evidence and be made part of the use of force package and if, applicable, used for investigatory purposes.

OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

ASSESSMENT: These provisions of this paragraph of the SA are contained in revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved and signed and partially implemented. There has been considerable training provided on these provisions to LCJ staff. LCJ staff are in the process of developing and implementing a use of force training program for supervisors who play a critical role in the use of force program. Video recordings of use of force incidents are maintained by the Deputy Warden. Supervisors are required to obtain photographs of reported injuries sustained by inmates during a use of force incident. The Deputy of Security developed and implemented a “use of force package” for each use of force incident

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which was impressive. The use of force package also includes video recordings of the use of force incidents.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy should continue to be implemented in order to be able to fully evaluate compliance with the SA.
2. During the next tour, I will be reviewing additional video recordings and photographs taken following use of force incidents.
3. LCJ staff should continue to implement separate “use of force package” for each use of force incident that contains all documents and evidence for every use of force incident.
k. LCJ shall establish an “early warning system” that will document and track correctional officers who regularly employ force on inmates and any complaints related to the excessive use of force, in order to alert LCJ administration to any potential need for retraining, problematic policies, or supervision lapses. A ppropriate LCJ leadership, supervisors, and investigative staff shall have access to this information and monitor the occurrences.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT: An early warning system is addressed in the revised Use of Force Policies and Procedures. The revised Use of Force policy and procedure has been approved and signed and implemented. An early warning system has been developed and implemented.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should continue to be implemented.
2. Concomitant with the implementation of the Use of Force Policy and Procedure, LCJ staff should continue to implement the early warning system described in the revised Use of Force Policy and Procedure.
l. LCJ shall ensure that a supervisor is present during all planned uses of force.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
This provision is addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedure has been approved, signed and implemented. I reviewed planned uses of force and they consistently complied with this provision of the SA. S upervisors are deployed to planned uses of force events.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedure should continue to be implemented.
2. During the next tour I will be reviewing planned uses of force for continued compliance with this provision of the SA.
m. Where there is evidence of staff misconduct related to inappropriate or unnecessary force against inmates, LCJ shall initiate appropriate personnel actions and systemic remedies, as appropriate. L CJ shall discipline appropriately any correctional officer found to have:
(1) engaged in use of unnecessary or excessive force; (2) failed to report or report accurately the use of force; (3) retaliated against an inmate or other staff member for reporting the
use of excessive force; or (4) interfered or failed to cooperate with an internal investigation
regarding use of force.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedure contains the provisions of this paragraph of the SA. T he revised Use of Force Policies and Procedures have been approved, signed and implemented. LCJ staff make referrals for investigation when warranted and disciplinary action is taken.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. It is recommended that the revised Use of Force Policy and Procedure continue to be implemented.
2. During the next site visit I will be reviewing any IA investigations regarding staff use of force violations as well as personnel records.
n. LCJ shall develop and implement accountability policies and procedures for the effective and accurate maintenance, inventory and assignment of chemical and other security equipment.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policy and Procedures address incapacitating agents, electronic control devices and the use of the restraint chair. T he procedure for the maintenance, inventory and

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assignment for the electronic control device is addressed in the use of force policy. However, the policy does not contain those controls for restraint equipment such as handcuffs and leg irons. However, LCJ continues to maintain other policies and procedures governing all security equipment and have been cross-referenced with the Use of Force Policy and Procedure and contain the specific provisions of this paragraph of the SA. During this tour and in my previous tour I reviewed use of force incidents. I noted in my inspections that in many instances where the Taser was deployed, it was generally used on mentally ill inmates or in the intake area. Data collected by LCJ staff and RJS suggests that this pattern continues. Data provided suggests that there continues to be an over representation of uses of force involving mentally ill inmates. The implementation of the Use of Force Review Team was a positive step in helping identify this phenomena. T he DOJSA recommends that LCJ adopt a policy requiring the on-site verbal approval of Taser use against mentally ill inmates by a shift commander or higher rank, except under exigent circumstances to prevent imminent harm to the inmate and/or others. I concur with this recommendation as a component of the overall intervention process that needs to occur in helping reduce the inordinate use of the taser on mentally ill inmates.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. RJS staff should continue working with LCJ staff in addressing the proper use of the Taser and its application on mentally ill inmates as well as other types of force used on the mentally ill and to implement the recommendation made by the DOJSA as articulated above.
3. During the next tour I will be reviewing use of force reports and also assessing efforts LCJ staff have made on the proper use of the Taser.
4. LCJ staff should continue to review all uses of force involving mentally ill inmates with the Use of Force Review Team.
5. LCJ staff should continue to explore strategies for reducing uses of force incidents involving mentally ill inmates.
o. Use of Force Training:
(1) LCJ shall develop an effective and comprehensive training program in the appropriate use of force.
(2) LCJ shall ensure that correctional officers receive adequate training in LCJ’s use of force policies and procedures.
(3) LCJ shall ensure that correctional officers receive adequate training in use of force and defensive tactics.
(4) LCJ shall ensure that correctional officers receive pre-service and in-service training on reporting use of force and completing use of force reports.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE

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ASSESSMENT:
The staff training provisions for the requirements of this paragraph of the SA have been developed and implemented. Additional use of force instructors have been identified. A 40 hour training course on t he use of force for officers and supervisors has been developed and implemented. Approximately 97% of the correctional officers have been trained. An additional use of force training program is being developed for the supervisors. In addition to the above use of force training, there is a 4 hour in-service training component on t he use of force. T he supervisor training program has not yet been implemented due to budget constraints with the agency, but this provision applies only to correctional officers and not supervisors.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. LCJ should continue to provide staff training to all officers and supervisors on the use of force in accordance with their training schedule.
p. LCJ shall ensure that inmates may report allegations of the use of excessive force orally to any LCJ staff member, who shall reduce such reports to writing.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures contain the provisions of this paragraph of the SA. T he revised Use of Force Policies and Procedures have been approved signed and implemented. LCJ officials should continue to monitor this provision during the course of use of force reviews. Also, this reporting provision should be addressed in the Inmate Handbook so that inmates are fully aware of reporting avenue.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. LCJ staff should revise the Inmate Handbook and insert language that allows inmates to report allegations of the use of excessive force orally to any LCJ staff member.
q. LCJ shall ensure that Qualified Medical Staff question, outside the hearing of other inmates or correctional officers if appropriate, each inmate who reports for medical care with an injury, regarding the cause of the injury. If, in the course of the inmate’s medical encounter, a health care provider suspects staff-on-inmate abuse, that health care provider shall immediately:

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(1) take all appropriate steps to preserve evidence of the injury (e.g., photograph the injury and any other physical evidence);
(2) report the suspected abuse to the appropriate LCJ administrator;
(3) adequately document the matter in the inmate’s medical record; and
(4) complete an incident report.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policy and Procedure. The revised Use of Force Policy and Procedures has been approved signed and partially implemented. LCJ staff continue to work with the medical staff to ensure that the medical policies and procedures also contain the provisions of this paragraph of the SA.
RECOMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should continue to be implemented.
2. These provisions should also be addressed in the medical policies and procedures.
r. LCJ shall develop, assign, and train a team of specialized use of force investigators that will be charged with conducting investigations of use of force incidents. These use of force investigators shall receive at the outset of their assignment, specialized training in investigating use of force incidents and allegations.
OVERALL COMPLIANCE RATING: PARTIAL COMPLIANCE
ASSESSMENT:
These provisions of this paragraph of the SA are addressed in the revised Use of Force Policies and Procedures. The revised Use of Force Policies and Procedures have been approved, signed and partially implemented. The Sheriff has designated two Lake County Police investigators to serve as the specialized use of force investigators as required by this paragraph of the SA. During my previous tours I interviewed the Chief Investigator and noted that he has substantial experience in both criminal and administrative investigations and had served as Deputy Commander of Investigations for the Lake County Policy Department for approximately 6 1/ 2 years in addition to other law enforcement experience. The second investigator also possesses substantial investigative experience. LCJ staff reported that the investigative guideline manual for use by the specialized use of force investigators remains in draft form for allowing time to test currently used investigation processes. Once the processes have been found to be valid and reliable, the manual will be formally implemented.

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RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policy and Procedures should continue to be implemented.
2. It is further recommended that LCJ officials finalize and implement their investigative guideline manual for the use of force investigative process once it is determined to be valid and reliable.
3. I also recommend that the specialized use of force investigators receive formal training on t he revised Use of Force policy to further assist them in their investigative duties. This can be accomplished in a 2 to 3 hour training session.
s. LCJ shall ensure that incident reports, use of force reports and inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, that it is referred for investigation.
OVERALL COMPLIANCE RATING: SUBSTANTIAL COMPLIANCE
ASSESSMENT:
The revised Use of Force Policies and Procedures address the provisions of this paragraph of the SA. T he revised use of Force Policies and Procedures have been approved, signed and implemented. Supervisory staff and the inmate grievance supervisor screen inmate grievances for allegations of abuse as well as incident reports and use of force reports.
RECOMMENDATIONS FOR THE NEXT 6 MONTHS:
1. The revised Use of Force Policies and Procedures should be implemented. 2. During the next tour I will be reviewing specific instances regarding allegations of
staff misconduct for conformance with this provision of the SA.

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 U.S. Department of Justice Civil Rights Division
Assistant Attorney General 950 Pennsylvania Avenue, NW - RFK Washington, DC 20530
December 7, 2009
Roosevelt Allen, Jr., Commissioner, 1st District Gerry Scheub, Commissioner, 2nd District Frances DuPey, Commissioner, 3rd District Board of Commissioners Lake County, Indiana 2293 North Main Street Building A, 3rd Floor Crown Point, Indiana 46307
RE: Investigation of the Lake County Jail Dear Commissioners Allen, Scheub, and DuPey:
On September 12, 2008, we notified your office of our intention to investigate conditions at the Lake County Jail (“LCJ”) pursuant to the Civil Rights of Institutionalized Persons Act (“CRIPA”), 42 U.S.C. § 1997. Consistent with CRIPA’s requirements, we now write to report the current findings of our investigation and to recommend remedial measures needed to ensure that conditions at the LCJ meet federal constitutional requirements. See 42 U.S.C. § 1997b.
On December 15-17, 2008, the Department of Justice toured LCJ with correctional experts in the fields of suicide prevention and mental health care, medical care, and environmental conditions. These experts assisted us in reviewing records, interviewing staff, interviewing inmates, and inspecting facility living conditions. Before, during, and after our on-site inspection, we reviewed a large number of documents, including policies and procedures, incident reports, medical and mental health records, and other materials. During this investigation process, Lake County, Sheriff Roy Dominguez, and other LCJ officials cooperated fully with our review. We appreciate the assistance of Sheriff Dominguez and the LCJ staff and their level of professionalism and courtesy.
Consistent with our commitment to provide technical assistance and conduct a transparent investigation, we provided a exit debriefing at the conclusion of our on-site inspection. During this debriefing, our experts provided their initial

- 2 impressions and tentative concerns. Some of the concerns we expressed during the exit debriefing regarded LCJ’s dangerous and inadequate suicide prevention practices. We reiterated those concerns in a letter to Sheriff Dominguez dated January 7, 2009, regarding the urgent need to address suicide prevention measures.
We now write to advise you of the current overall findings of our investigation, the facts supporting them, and the minimum remedial measures that Lake County needs to take to address the deficiencies we identify. Pursuant to 42 U.S.C. § 1997b, we conclude that certain conditions at the LCJ violate the constitutional rights of inmates. We find that the LCJ engages in a pattern or practice of conduct that subjects inmates to systemic violations of federal constitutional rights, specifically in regard to: (1) suicide prevention, (2) mental health care, (3) the medical care, and (4) sanitary and safe living conditions.
I. BACKGROUND A. FACILITY DESCRIPTION
The LCJ is located in Crown Point, Indiana, approximately twenty miles south of Gary, Indiana, and is operated by the Lake County Sheriff’s Office.1 The Chief Warden of the LCJ works for the Sheriff’s Office’s Corrections Division.2 The LCJ houses adult male and female inmates who are felons, gross misdemeanants, misdemeanants, pre-trial detainees, juvenile offenders, witnesses, or others being detained in protective custody.3 The LCJ has an inmate capacity of approximately 1040,4 and employs approximately 179 sworn merit correctional officers and 26 civilian employees.5 During our December 2008 tour, the LCJ inmate population counted at approximately 1053. The LCJ comprised two buildings labeled the old and new jail and situated on five floors.
1 http://www.lakecountysheriff.com. 2 http://www.lakecountysheriff.com. 3 http://www.lakecountysheriff.com. Throughout this letter we use the term “inmates” to refer to those persons confined at the LCJ, regardless of status. 4 Lake County Jail Annual Report 2007. 5 Lake County Jail Annual Report 2007.

- 3 B. LEGAL FRAMEWORK
CRIPA authorizes the United States Attorney General to investigate and take appropriate action to enforce the constitutional rights of jail inmates subject to a pattern or practice of unconstitutional conduct or conditions. 42 U.S.C. § 1997. The Fourteenth Amendment mandates that jails must provide pre-trial inmates “at least those constitutional rights . . . enjoyed by convicted prisoners,” including Eighth Amendment rights. Bell v. Wolfish, 441 U.S. 520, 545 (1979). Under the Eighth Amendment, prison officials have an affirmative duty to ensure that inmates receive adequate food, clothing, shelter, and medical care. Farmer v. Brennan, 511 U.S. 825, 832 (1994). The Constitution imposes a duty on jails to ensure an inmate’s safety and general well-being. County of Sacramento v. Lewis, 523 U.S. 833, 851 (1998) (citing DeShaney v. Winnebago County Dep’t of Soc. Servs., 489 U.S. 189, 199-200 (1989)). This duty includes the duty to prevent the unreasonable risk of serious harm, even if such harm has not yet occurred. See Helling v. McKinney, 509 U.S. 25, 33 (1993). Thus, jails must protect inmates not only from present and continuing harm, but also from future harm. Id. This protection extends to the risk of suicide and self-harm. See Matos v. O'Sullivan, 335 F.3d 553, 557 (7th Cir. 2003); Hall v. Ryan, 957 F.2d 402, 406 (7th Cir. 1992) (noting that prisoners have a constitutional right “to be protected from self-destructive tendencies,” including suicide).
The Constitution also mandates that jails provide inmates adequate medical and mental health care, including psychological and psychiatric services. Farmer, 511 U.S. at 832. Prison officials violate inmates’ constitutional rights when the officials exhibit deliberate indifference to inmates’ serious medical needs. See Estelle v. Gamble, 429 U.S. 97, 102 (1976).
Jails must provide “reasonably sanitary and safe” living conditions. Farmer 511 U.S. at 832. The Constitution requires jails to ensure that environmental conditions do not pose serious risks to inmates’ health and safety, such as deficient sanitation, inadequate fire safety, inadequate ventilation, and pest infestation. Vinning-El v. Long, 482 F.3d 923, 924-25 (7th Cir. 2007).
II. FINDINGS A. SUICIDE PREVENTION
The Constitution requires the LCJ to protect inmates from suicide and self harm. See, e.g., Hall, 957 F.2d at 406. This constitutional requirement mandates adequate suicide prevention measures, including appropriate screening by a qualified mental health professional to assess suicide risk, appropriate supervision,

- 4 observation, and monitoring of those inmates identified as at risk of suicide, appropriate communication between correctional health care and correctional staff, and appropriate multi-disciplinary treatment plans. The suicide prevention and management process at the LCJ is grossly inadequate.
Staff we interviewed reported that there have been seven completed suicides in the past four years. Five completed suicides occurred in the past two years, a rate which is more than five times the national average.6 As we explain in further detail below, the LCJ lacks the appropriate structure, staff, and training to adequately protect inmates at risk of self-harm.
At intake, unqualified non-mental health clinicians conduct suicide screenings. These screenings fail to provide any estimate of risk of self-harm or to document any management plans. Screenings are not reviewed by a licensed and credentialed mental health professional for quality and timeliness. Moreover, access to appropriate mental health professionals is poor, as is communication between correctional and mental health staff. The following example highlights inadequate and contradictory initial suicide risk assessments, inadequate psychotropic medication management, inadequate treatment and overall attention from mental health staff, and inadequate mental status exams and suicide reassessments:
! On February 27, 2008, the LCJ conducted an initial suicide risk assessment of inmate A.A.,7 with contradictory findings. One portion indicated no past psychiatric history (medication or treatment) and no previous suicide attempts, while other portions simultaneously listed three current psychotropic medication prescriptions, and described his medical complications as “bipolar/depression.” The assessment found “no need for mental health treatment indicated at this time.” Thus, the inmate was not provided with a psychiatric assessment or psychotropic medications. Unqualified staff made a similarly flawed second, March 10, 2008, suicide risk assessment, again indicating no current or past psychotropic medications, and no treatment history. Compared to the
6 The national average suicide rate in jails in the United States is 0.47 suicides per 1000 inmates per year. Thus for the LCJ’s average inmate population of 1000, 7 suicides in 4 years equals an average of 1.75 suicides per year, and 5 suicides in 2 years equals an average of 2.5 suicides per year.
7 To protect inmates’ privacy, we have used fictional inmate initials.

- 5 first assessment, the March assessment changed medical complications to “none/unable to confirm anxiety with doctor.” Again, the second assessment found “no need for mental health treatment indicated at this time.” Contradicting this assessment, however, a medical screen conducted the same day indicated that A.A. had been admitted to the LCJ previously in 2005 and 2007, had been taking pyschotropic medications, and the LCJ had previously treated him for “depression/anger.” A.A. was not seen by a psychiatrist until March 18, 2008, nearly three weeks after his admission. The psychiatrist’s assessment described a bipolar disorder for the past six years, listed a history of several psychotropic medications, and a history of suicidal ideation/attempt, including an incident where the inmate cut his wrists related to family issues a few months earlier in December 2007. The psychiatrist ordered psychotropic medications and a return to the clinic in four weeks. Thus, the record shows that the inmate was not seen by a qualified mental health professional or given psychotropic medications until at least three weeks after his admission. The inmate’s record indicates that, throughout April 2008, the inmate made multiple requests for counseling regarding changing his medications (because he was only sleeping two to three hours a night), and made several suicidal statements, which staff assessed as ploys to get out of his present unit. In one suicidal note, the inmate concludes with “last night when everybody was sleeping I tried to hang myself but my string broke. Tonight I’m going to try with my blanket. I will succeed.” On April 29, 2008, a counselor put the inmate on full suicide precautions. The inmate’s record reveals that two days later, on May 1, 2008, the psychiatrist preformed a cursory assessment, concluding that the inmate was on medication, was not depressed, did not have suicidal ideation, but had a history of suicidal ideation/attempt. Based on this cursory assessment, the psychiatrist took the inmate off suicide precautions and returned him to general population. Three days later, on May 5, 2008, the inmate hanged himself in his cell. If the LCJ identifies an inmate at intake as possibly representing a suicidal or self-harm risk, staff may place the inmate on “full suicide,” which requires an LCJ correctional officer to monitor the inmate. Because a physician or qualified mental health professional often does not review this designation, it results in the LCJ placing many inmates on suicide watch who do not require that level of

- 6 supervision, which places an unreasonable demand on LCJ staff to supervise a large number of inmates. The LCJ monitors inmates on suicide watch with staff making visual checks every 15 minutes or by remote video camera. The LCJ fails to adequately monitor inmates with both these systems.
Regarding the visual 15 minute checks, LCJ custody staff should be making these checks at least every 15 minutes and noting the check on the inmate’s suicide check log. We observed that staff failed to make these checks every 15 minutes, yet they would inaccurately record on the inmate’s suicide check log that such checks were completed every 15 minutes. We also reviewed log sheets with multiple blanks and log sheets with single signatures purporting to cover several 15 minute periods. One inmate, B.B., reported that staff failed to check on her every 15 minutes, but rather would “take the sheet with them.”
We also found inadequate LCJ’s camera supervision. We observed one correctional officer attempt to monitor up to 18 cameras at any given time from a control office where that officer had multiple, additional responsibilities. The example below highlights the deadly consequences of the LCJ’s failure to properly monitor its cameras:
! Shortly after his arrest in September 2006, C.C. committed suicide by hanging himself with his T-shirt in an LCJ intake cell. The EMTs who initially assessed C.C. stated that C.C. told them that he suffered from anxiety and depression, and was currently taking Xanax. Our review of the LCJ camera video of the intake cell shows C.C. tying his T-shirt into a ligature and securing the T-shirt ligature around his neck and a bathroom stall. The video further shows C.C. hanging from the bathroom stall for approximately eighteen minutes before LCJ staff discovered him. The video further reveals that staff let another inmate out of the holding cell - after C.C. had already been hanging for approximately eight minutes - and still did not discover C.C. hanging from the stall for an additional nine minutes.
As detailed below, we note that even after this tragic incident, the LCJ has not rectified its substandard monitoring of inmates at risk of suicide. Beyond the obvious failure to monitor surveillance cameras, this example further highlights that the LCJ needs to assess an inmate’s suicide risk with a qualified mental health professional. A qualified mental health professional might have placed the recently arrested inmate, who indicated that he took Xanax and suffered from anxiety and depression, on suicide precautions.
In addition to the alarming number of recent past suicides, we found that the inadequate suicide management processes and inherently dangerous care of

- 7 inmates with a risk of suicide continues at the LCJ. The following examples show that, like the completed suicide examples above, the LCJ continues to ignore inmates on full suicide watch and fails to properly assess inmates with suicidal ideation:
! During our December 2008 tour, we observed medical, mental health, and custody staff ignore inmate D.D., who was screaming for assistance while on “full suicide” camera watch. Additionally, this inmate had just been discharged from a hospital the previous day. When a counselor eventually visited the inmate, and alerted both the Director of Nursing and the mental health manager, the staff still did not promptly assess the inmate for her mental health needs and suicide potential. Instead, staff responded that the psychiatrist, who happened to be at the LCJ for one of the psychiatrist’s two four-hour shifts per week, would eventually see the inmate. Beyond this potentially harmful delay, this procedure fails to account for who would see inmates in obvious acute distress if the psychiatrist happened to not be on site that day.
! In November 2008, a correctional officer found E.E. standing on a toilet stating that he wanted to kill himself. The correctional officer called a mental health counselor, who after speaking only with the correctional officer, agreed that the inmate was “just kidding.” The counselor conducted no face-to-face assessment and completed no suicide risk assessment form.
The LCJ’s inadequate medication administration, further detailed in the medical section below, also increases the danger to inmates at risk of suicide. The LCJ’s medication administration system improperly gives inmates all of their medications for the day at a single time, expecting inmates to self-administer their medication throughout the day. This inherently dangerous practice provides inmates with medications to be taken at whatever time the inmate chooses, and allows the inmate to hoard, trade, or overdose their medications. The LCJ does administer medications to a few inmates on a “split and watch,” basis, where the nurse splits the inmate’s daily medication, and watches the inmate take a morning dose and an evening dose, however this practice is inconsistent.
While the documents LCJ produced did not identify suicide attempts related to inadequate medication management practices, our interviews with inmates and staff revealed that inmates have attempted to overdose on their medications and possibly the medications of other inmates, and that the clinical staff and custody staff routinely fail to watch inmates take their medications, placing those at risk of suicide in significant peril. We found many dangerous examples, including:

- 8 ! Inmate F.F. reported that he was in the mental health crisis unit
because he attempted to kill himself by overdose on numerous pyschotropic medications in December 2008. Despite his record indicating that he previously attempted suicide by overdose in 2004, and that he indicated “yes” on his suicide screening to a past history of attempted suicide, LCJ’s self-administration practice allowed him to hoard his medications and attempt suicide. This inmate told us “I stored it up, took it all - tried to kill myself.” ! The LCJ gives G.G. all his medications once a day to take as he chooses, despite his self-reported suicidal ideation and being placed on suicide watch. ! Inmate H.H. reported that LCJ gives him five different psychotropic medications, to self-administer throughout the day. LCJ has given him as much as 1300 mgs of Haldol at a single time, a potentially lethal amount if ingested all at once.8 His medication administration record shows nursing initials that inaccurately indicate that nurses personally administer his medication twice a day. ! Inmate J.J. attempted to hang himself approximately two months before our visit. Despite this suicide attempt, his counselor sees him only once a month, and the LCJ gives him pychotropic medications to self-administer throughout the day. ! Inmate K.K. reported that she has a chemical dependency problem and had just attempted suicide in August 2008. She stated that a counselor does not see her on a regular basis and that she did not see a counselor until two weeks after her admission. Despite her suicide attempt and a self-reported chemical dependency problem, LCJ gives her psychotropic and other medications to self-administer. In addition to the risk of self-overdose, this practice allows inmates to take dangerous medications without a prescription. One inmate confirmed that he saves his psychotropic medications and makes them available to other inmates.
8 The maximum dose of Haldol is 100 mgs per day, but prescriptions over 60 mgs per day are extremely rare, and appropriate only in a hospital setting. Overdose dangers include seizures, respiratory depression, and possibly death.

- 9 Overall, the LCJ’s suicide prevention and management processes fail to properly screen and assess inmates, and fails to adequately monitor and treat inmates with suicide risks. B. MENTAL HEALTH CARE The Constitution requires LCJ to provide inmates adequate mental health care, including psychological and psychiatric services. Farmer, 511 U.S. at 832. Our investigation revealed that the LCJ’s mental health care and suicide prevention practices fall below the minimum constitutionally required standards of care. Particularly, we found the LCJ’s mental health care services were constitutionally deficient in the following areas: (1) staffing; (2) intake and referral process; (3) sick call process; (4) treatment planning and services; (5) medication management; and (6) quality improvement and quality management program. These deficient LCJ practices cause inmate harm and create an unreasonable risk of harm. 1. Inadequate Staffing We found that the LCJ employs an inadequate number of staff to provide inmates with a constitutionally adequate mental health program. At the time of our tour, the LCJ employed the full time equivalent (“FTE”) of 3.2 mental health staff, comprised of 3 mental health counselors and 0.2 (i.e., 8 hours per week) of a psychiatrist’s services.9 This allocation of staffing is inadequate for LCJ’s average daily population of approximately 1,000 inmates, and an intake service that processes 15,000 intakes per year. For its population, the LCJ needs at least 7-10 mental health counselors and 1.5-2.0 FTEs in psychiatry. Under-staffing currently limits the LCJ to a response-oriented, crisis management mental health program, rather than the preventive program that the Constitution requires. This under-staffing causes gaps in care, for example: ! Inmate H.H. reported that he currently was taking five different
psychotropic medications, but that he had not seen the psychiatrist in three months. ! Inmate L.L., a juvenile, reported that he has only seen a counselor “three or four times” despite being incarcerated at the LCJ for the previous seven months. Mental health staff should have counseled
9 We also note that the LCJ was unable to produce credentialing records for its counselors and psychiatrists.

- 10 this juvenile inmate at least monthly, according to LCJ policy and the generally accepted professional standard. ! Inmate J.J., reported that he had attempted to hang himself in the last four months, has Bipolar disorder, and currently was taking two different psychotropic medications. Despite these special needs, the counselor sees him only once a month, and the psychiatrist does not regularly see him to monitor his medication compliance or his symptoms of mental illness. Compared to LCJ’s crisis response-oriented program, an adequate proactive mental health program includes comprehensive assessments, psychosocial evaluations, multi-disciplinary treatment planning, individual and group therapies, and services specific to special need inmates, such as juveniles and women. 2. Inadequate Intake and Referral Process EMTs and psychology technicians perform the intake mental health screenings and evaluations. These intake functions should be performed by qualified mental health staff. Consequently, the LCJ appears to fail to identify many inmates who need mental health services. The LCJ identifies 14% of inmates as needing mental health services, but the national average for its population is 18-30%. In addition, the staff who do perform the screenings fail to adequately complete them. Staff take these screenings at booking, usually in a non-confidential setting. This process conflicts with professional standards that require confidential mental health evaluations to be completed after the inmate has been in jail for up to 14 days. Further, no qualified mental health staff review the screenings for adequacy. These flawed screening evaluations hurt the adequacy of the referral process, which is based on these evaluations. Referrals between mental health and medical staff suffer serious communication problems. Our interviews revealed that both groups expect the other group to perform direct patient assessment and care duties, for which both groups should take responsibility. For example, as detailed above, we witnessed medical staff ignore a screaming inmate who was clearly in distress and on suicide camera watch because they claimed the inmate had a “mental health” problem, and mental health staff ignored this inmate because the inmate had a “medication problem.” Custody staff monitoring the camera called for neither medical nor mental health staff. These types of collaboration and communication failures can cause serious injury or death.

- 11 3. Inadequate Sick Call Process The LCJ sick call process is not consistent with generally accepted correctional standards of triaging and responding to sick call requests within 24 hours. Contrary to this 24-hour standard, documents we reviewed showed that the LCJ’s sick call process envisioned that medical staff should respond to sick call card requests within 48 hours. We found that the process relies on custody staff giving inmates sick call cards upon request, custody staff delivering these cards to a central location, nursing staff triaging the sick call cards and then providing them to mental health staff. While documents envisioned the completion of this process within 48 hours, an LCJ audit revealed that the delay in medical receiving sick call requests ranged from 72 hours to several days. Moreover, this delay simply marked the receipt of the sick call card and did not consider the additional delay of actually responding to the sick call request. Therefore, this process allows for harmful extended treatment delays for inmates in serious crisis and in need of emergency or urgent evaluation. Further, the LCJ does not track whether responses are as prompt as necessary, addressed by the appropriate provider, or resulted in a reasonable outcome such as modification or assignment of services or treatment. The flawed intake and referral process described above compounds this problematic sick call process, because the flawed intake and referrals leave inmates with only this flawed sick call process to alert staff to their needs. 4. Inadequate Treatment Planning and Services Generally accepted correctional standards require that the LCJ develop and use comprehensive multi-disciplinary treatment plans and services. Documents and interviews with staff and inmates revealed that the LCJ violates this standard by having no treatment plans, other than an initial treatment plan that the psychiatrist may author for the few individuals that he may see during the eight hours per week that he works at the LCJ. We found no comprehensive treatment planning process, no scheduled treatment planning conferences, and no special needs treatment plans for juveniles. Policies and procedures fail to require: (1) that a treatment plan begin as an initial plan when the mental health clinician first sees the inmate; (2) the completion of a more comprehensive treatment plan within 10-14 days of admission; and (3) the periodic reevaluation of treatment plans for those inmates residing at the LCJ for extended periods. A multi-disciplinary comprehensive treatment model includes mental health, medical, and nursing staff because of the essential roles that they play in the treatment and management of inmates in a correctional environment. Compared to this multi-disciplinary comprehensive model, the LCJ’s current practice is for counselors to write a “Diagnostic Formulation,” without a qualified mental health

- 12 staff completing a mental health evaluation, and without the psychiatrist writing a progress note/medication review. Medical records that we reviewed contained no problem list to allow a reader to easily ascertain for what a specific inmate is being treated, including mental health problems, such as Schizophrenia or Depression, but also medical problems such as asthma, diabetes, or hypertension. Examples of inmates with inadequate treatment plans include:
! Inmate M.M., who had been at LCJ for four months, reported that he had been taking psychotropic medications for approximately the previous nine years, and received residential treatment for approximately the last two years. LCJ’s mental health suicide risk assessment and psychiatric screening of this inmate list “no” as answers to medications before admission and a past history of treatment. The medical history and screening listed similar “no” answers, and failed to refer him to the mental health department. After approximately three months, a mental health professional completed a Diagnostic Formulation. The LCJ eventually diagnosed him with Schizophrenia, and put him on suicide precautions. LCJ discontinued his suicide precautions with no indication that a physician interviewed the inmate in-person. The record contained no evidence of a long or short-term treatment plan, with the only treatment references dealing with medications and placement on suicide precautions when the inmate was in a crisis.
! We interviewed inmate G.G. on the mental health crisis unit. He reported that LCJ placed him on the crisis unit for the previous 15 days because he had stated he was suicidal. His record indicated that back in April 2008 he answered “yes” on his suicide risk assessment, but that no one referred him to mental health staff. Eventually, a nurse practitioner saw him a month later. A November 2008 psychiatric note was illegible, and therefore unhelpful in determining what treatment LCJ provided to this inmate. This inmate’s record contained no comprehensive treatment planning or discussion of his needs.
! Inmate N.N.’s record indicated he entered the LCJ on December 11, 2007, with an incomplete suicide screening and no mental health evaluation. On December 22, 2007, a progress note labeled him as a “full suicide” risk. His medication records indicated orders for Paxil and Trazodone in January, June, July, and September 2008, without a psychiatrist ever seeing him. His record contained no evidence of a comprehensive or multi-disciplinary treatment plan.

- 13 Regarding actual treatment services, the LCJ improperly delegates most services to the nursing staff, including medication management, the “split and watch” process for administration of medication, the writing of “full suicide” designations for inmates, and the discontinuation of medications if nursing staff believes that an inmate may be hoarding medication. The mental health staff conduct limited psychosocial “contact” or “rounds,” but they fail to give any form of individual therapy or group therapy, despite the policies and procedures that state that the LCJ will provide group therapy, individual therapy, and psychosocial interventions. 5. Inadequate Medication Management As described above with regard to the management of potentially suicidal inmates and also detailed in the medical care section below, the LCJ practices seriously flawed and dangerous medication management, including nurses improperly writing and discontinuing medical orders and inadequate security controls. 6. Inadequate Quality Improvement and Quality Management Program Generally accepted correctional mental health standards call for adequate quality assurance review and quality improvement tools. These tools are necessary to examine the effectiveness of the mental health care delivered and to implement corrective action so that the quality of care is improved. The LCJ poorly manages its existing Continuous Quality Improvement (“CQI”) process. While the quality improvement committee’s membership includes the mental health manager, no psychiatrist or licensed independent mental health professional sits on the committee. Moreover, our review of the minutes of meetings revealed that the committee meets only quarterly, that even these meetings do not consistently take place as scheduled, and that the discussion topics primarily deal with medical issues, rather a balance between medical and mental health issues. This quality improvement committee does not produce meaningful corrective action plans, nor does it assign these action plans to specific personnel with a requirement to report and document plan implementation. Specifically related to mental health issues, the LCJ does not meaningfully measure, follow, or document the quality or timeliness of important mental health processes such as assessments, suicide prevention evaluations, suicide management, treatment planning, medication management, and treatment services. The LCJ needs to completely revise its quality improvement and quality management program.

C. MEDICAL CARE

- 14 -

The Constitution requires that LCJ provide adequate medical care to address inmates’ serious medical needs. Farmer, 511 U.S. at 832; Estelle, 429 U.S. at 102. The LCJ must employ functional systems to provide adequate medical care and treatment to its inmates, particularly in a jail the size of LCJ. These systems should include an initial screening process, a comprehensive health assessment for longer-term inmates, a sick call process, acute and chronic care clinics, infection control mechanisms, medical record keeping, medication administration, qualified medical staff, a professional management structure, and a quality assurance component to evaluate and improve the above systems. Our investigation revealed that the LCJ’s medical care practices fall below the minimum constitutionally required standards of care. Particularly, we found constitutionally inadequate LCJ’s: (1) medical staffing; (2) access to medical care; (3) acute and chronic medical care; (4) comprehensive health assessments; (5) medication administration; (6) medical records; and (7) quality improvement. These deficient practices cause inmate harm and create an unreasonable risk of harm.

1. Inadequate Medical Staffing and Organization

Medical care at LCJ is disorganized and understaffed. Consequently, the LCJ inadequately trains and supervises the clinical staff. Many of the issues relating to the LCJ’s inadequate medical care discussed below derive from this poor organizational structure, low level of professional staffing, and lack of professional health care oversight of clinical employees and contractors.

LCJ provides medical care for its inmates through several personnel each reporting to separate entities: EMTs who report to Lake County; psychology technicians, nurses, dentists, and physicians who report to a contractor; and counselors and psychiatrists who report to a different contractor. In January, the LCJ planned to move the EMTs onto the Med Staff contract. The aforementioned providers engage in little formal communication, and each provider reported through a different deputy warden. None of these wardens had any health care administration experience.

The above chaotic health care structure results in inadequate supervision of the system’s health care providers. Outside of non-health care related administrative functions such as patient counts, the LCJ does not monitor the performance of any clinical activities. The director of nursing does not supervise the EMTs, who are responsible for intake screening, and these EMTs receive little training and supervision. The mental health staff do not supervise the psychology technicians, and these technicians receive little training and supervision. We found no lesson plan for training and supervision of the EMTs and psychology technicians.

- 15 A physician does not formally supervise the nurse practitioner. Furthermore, the LCJ does not provide inmates a copy of the inmate handbook, and has established a co-payment system at least double that of a typical similar sized jail.
The current number of LCJ staff cannot accomplish the critical clinical and administrative objectives of an adequate health care system. LCJ has only 1 to 5 hours of physician time per week, 2 hours of dentist time, and 1.2 FTE nurse practitioners. Similar sized facilities employ at least 2 FTE licensed independent practitioners and a full-time dentist. At the time of our tour, the LCJ had failed to fill a nurse practitioner vacancy for more than a year.
Insufficient dentist time inappropriately limits dental care to prescription for antibiotics and extractions. Similarly deficient, the infectious disease physician visits the LCJ for only two hours, two to four times per month.
In sum, poor organization, the absence of communication between disparate health care providers, the lack of appropriate supervision of clinical staff, and overall inadequate staffing contribute substantially to the LCJ’s inadequate medical care practices.
2. Inadequate Access to Medical Care We found that the LCJ provides inmates constitutionally inadequate access to medical care. As detailed below, we found problems with medical screenings and sick call, poor training, long waits for medical attention, infection control, high co-payments, confidentiality, and poor and non-existent documentation Inmates’ access to medical care through screening and sick call requests is inadequate. As stated above, untrained and unsupervised EMTs conduct the initial screening of inmates. Once booked, inmates’ only access to medical care comes through sick call requests. The mental health section above detailed the overall flaws with access to, processing, and tracking of sick call slips. Particular to medical care, we further note that a health care clinician only sees inmates once per week. This sick call process falls well below nationally-accepted standards of correctional care. Consequently, this wait for medical care violates constitutional minimums, leaving significant inmate medical needs inadequately addressed or completely unmet. For example, inmates wait approximately eight weeks for dental care. This wait is significantly too long, particularly for urgent problems such as abscesses and pain. From our records review, we found that several inmates had up to a four-day lag for care for skin abscesses and received no follow-up care. In another instance, an inmate acquired a skin infection in LCJ and waited five days for medical staff to

- 16 see him. The LCJ never provided follow-up care to several other inmates with skin wounds. Another inmate had a lump that the LCJ never addressed. Still another inmate suffered a two-month lag for care of symptoms suggesting a sexually transmitted disease. In all these cases, the LCJ provided substandard and poorly documented care.
With regard to the care and treatment of skin infections, the LCJ fails to maintain any logs. This absence of logs makes it impossible to track the incidences of skin infections within the LCJ to appropriately monitor the frequency and prevalence of such infections. Additionally, the LCJ fails to take the vital signs of the inmates it monitors for potentially life-threatening withdrawal from alcohol or other substances.
Nurses do not adequately review inmates whom staff electrically shock with TASERs during use of force incidents. We reviewed the use of TASER force on ten inmates over a three month period. Nursing evaluations were missing in five of those records and the LCJ could not find two of the records. Furthermore, the LCJ knew that seven of the ten inmates had mental illnesses, but their records contained little information regarding their mental illness or mental health interventions. We found that the LCJ could have possibly avoided at least six of these use of force incidents if the LCJ had adequately evaluated these inmates for mental health issues.
The LCJ’s medical record progress notes from sick calls are poor or non-existent. When we showed the director of nursing the progress notes for eight inmates seen by the nurse practitioner, the director of nursing found the notes illegible. Medical records for several inmates contained no progress reports or documented examination at all. Regarding primary physicians, we reviewed numerous medical records of inmates scheduled for sick call. Over half of these records contained no progress note, and the LCJ’s unacceptably high no-show rate of over fifty-percent makes it likely a physician never saw these inmates. Furthermore, the inmates were not seen within seven days following the scheduled visit. Finally, we found that the physician interviewed several patients with significant health care needs such as HIV infection and/or viral hepatitis, but the physician failed to document findings in the medical records. This lack of documentation made it impossible to evaluate access to or quality of care for these inmates. We did note several inadequate infection control practices dangerous to the health and safety of both staff and inmates. For example, the examination room in the booking area contained unsecured hazardous waste, chemicals, and sharps. Medications laid unsecured in the clinic area. Many of the mattresses in the housing units were cracked, making them impossible to disinfect.

- 17 LCJ’s co-payment system departs from minimally accepted correctional standards. LCJ’s co-payment is at least double that of a typical similar sized jail. These high co-payments along with the lack of adequate waivers in specialized circumstances bar inmates’ access to care. Jails similar to LCJ typically waive co-payments for communicable disease (such as skin infections), chronic disease care, comprehensive health assessments, and pregnancy care. LCJ does not waive these co-payments. Several inmates indicated that these high co-payments barred their access to care. Thus, this non-waiver and high co-payment system forces inmates to go without necessary care for serious medical problems. Moreover, in the case of communicable diseases, not only does this system harm the inmate, but it also puts the general public at risk of harm. Finally, inmates are often interviewed in the clinic areas in the presence of, or within earshot of, correctional officers, thus compromising inmates’ privacy and ability to communicate their medical needs. 3. Inadequate Acute and Chronic Medical Care LCJ fails to provide inmates constitutionally adequate acute and chronic medical care. Regarding inadequate acute care, LCJ records revealed several instances of jail-acquired skin infections. Jails should provide inmates with skin infections daily documented wound care and regular follow-ups by a physician or mid-level practitioner. The LCJ diagnosed and treated the majority of these infected inmates without a physician evaluation or physician order for the antibiotic prescribed. The LCJ’s documentation of wound care and physician follow-up was nearly absent. We noted a startling case of an inmate, O.O., with a history of prostate disease who had difficulty urinating without medication. He waited three days until a physician saw him, even when nursing staff had already catheterized him on at least two occasions. Proper medication, which was never ordered, could have prevented this unnecessary catheterization. Further, the inmate, who was withdrawing from alcohol, is another example of the LCJ’s failure to document vital signs during withdrawal. Moreover, we reviewed the charts of ten inmates whom the LCJ had treated for withdrawal from alcohol or other substances and only two records showed documented vital signs and appropriate treatment for the withdrawal. We also reviewed the medical record of an inmate, P.P., diagnosed with syphilis, based upon a test that indicated an old infection or, alternatively, liver disease. The LCJ improperly gave him three unnecessary intramuscular injections as if he had acute syphilis. Furthermore, the clinical staff never checked with the county health department’s database for his history of treatment.

- 18 Regarding chronic care, LCJ fails to follow generally accepted correctional care practices for treating chronic illnesses, which causes inadequate care for inmates’ chronic conditions. LCJ has no system to track and monitor inmates with chronic care conditions nor a chronic care clinic to adequately manage inmates needing chronic care treatment and follow-up. From our record reviews and interviews, we discovered that the LCJ failed to give inmates with asthma a comprehensive health assessment, even though these inmates had stayed in the LCJ for more than 30 days, nor had the LCJ appropriately measured or monitored their condition. Another inmate with known hypothyroidism, Q.Q., did not receive a comprehensive health assessment and had no prescription for life-sustaining thyroid medication. The LCJ also fails to adequately monitor inmates with diabetes. Of the records we examined of inmates with diabetes, the LCJ had measured the hemoglobin of only 67% within the past 3 months and measured the cholesterol of only 58% within the past 12 months. Furthermore, only 1 inmate had any documentation of a urinary measurement within the past 12 months. These practices fall well below generally accepted minimal standards for correctional care for diabetes. For inmates with seizure disorders, despite inmates reporting medication at booking, the LCJ failed to place these inmates on seizure medications, and their records showed no clinical documentation justifying the discontinuation of these medications. Medical records for inmates with HIV and viral hepatitis C had no progress notes, which prevents other clinical staff from coordinating or providing continuity of care or from evaluating the inmate’s care. 4. Inadequate Comprehensive Health Assessment The LCJ fails to perform comprehensive health assessments that generally accepted correctional practices require. Longer term inmates require a more comprehensive health assessment in addition to the screening at booking. The generally accepted profession standard of care in jails is for a jail to conduct a physical examination, including a comprehensive medical history, within 14 days of booking. Longer-term juveniles also should have immunization records. We reviewed the medical records of 33 inmates in custody beyond fourteen days. None of the 33 inmates had a comprehensive health care assessment. As noted above, this lack of a health assessment can have increased harmful risks for inmates with acute or chronic illnesses. We also evaluated the records of all of the juveniles at the LCJ; none had a comprehensive health assessment, immunization record, or mental health evaluation. 5. Inadequate Medication Administration The LCJ practices seriously flawed and dangerous medication management. The LCJ’s medication administration staff engage in several inappropriate

- 19 medication administration practices, including inappropriate nursing decisions and inadequate security controls.
Interviews and the LCJ’s medical records revealed that nurses practice beyond the scope of their licenses by improperly writing and discontinuing medical orders without specific direction from a physician. Regarding improperly writing orders, the LCJ has standing orders authorizing nurses to diagnose illnesses, and to prescribe and administer non-emergency medications without a physician’s order. These standing orders authorize nurses to record administration of these medications as “T.O. [telephone order] Dr. Pierce/nurse’s name.” These practices go well beyond the scope of a nurse’s license and misrepresent that the administration of the medications was pursuant to a direct and individualized telephone order.
Regarding discontinuation of medication, nursing staff automatically stop medications, without a physician’s order, for patients who do not adhere to their prescriptions. Rather than automatically stopping the medications, generally accepted correctional standards counsel that any patient who does not follow his or her prescription regimen should be counseled and asked to sign a refusal form for medications missed on three consecutive days and should be reported to the prescribing physician. Again, these nurses falsely designate these orders “as per physician” because LCJ policy requires that they write that designation on the order.
This practice obviously puts inmates at risk of harm from ill-advised medical orders. We found many examples where nurses improperly discontinued medications, not for medical reasons, but because the nurse thought an inmate was hoarding medication. For example:
! Inmate R.R.’s record indicated a history of suicide watch, diagnosis of Schizophrenia, and a prescription for a psychotropic medication. His record showed that a nurse unilaterally discontinued his medication as “per Dr. Robbins,” based on finding 14 tablets of the psychotropic medication hoarded in his cell. This inmate’s record failed to document any psychiatrist involvement in the discontinuation of his medication or any psychiatric progress note describing any assessment or treatment of his suicide risk.
Beyond nurses practicing outside their licenses, we found medication security problems. The medication room was unsecured. Staff leave the room unlocked, giving inmates access to drugs and sharps. Medications laid loose in a box on the floor of the nursing stations. We note that these loose medications included controlled substances, a particularly dangerous substandard practice. Staff also inappropriately used the medication refrigerator to store food.

- 20 We also reiterate that, as explained in the suicide prevention section above, LCJ generally administers medications only once per day. This practice encourages hoarding and diversion of medications. The staff also inaccurately document that they have directly observed inmates taking these medications throughout the day. Finally, LCJ lacks a Pharmacy and Therapeutics Committee or a process to determine whether certain types of medications may be appropriately prescribed at LCJ. This process would correct the conflicts we noted between the medical director and the corporate administrator of Med Staff over the use of particular drugs prescribed by the medical director. 6. Inadequate Medical Records Medical records are disorganized and lack essential information. At the time of our visit, LCJ had a two to three-month lag in filing medication administration records. The psychiatrist and nurse practitioner wrote illegible notes, making their clinical notes unhelpful. The infectious disease physician did not document his clinical encounters in the records at all. Furthermore, staff did not organize notes in any coherent fashion, such as the standard format of Subjective information, Objective information, an Assessment, and a Plan (“SOAP”). The records also did not contain an index sheet, which medical professionals generally refer to as a problem list. As stated earlier, because LCJ fails to provide a sufficient number of sick call forms for the inmates, inmates use scraps of paper that staff often randomly staple into the medical records. These scraps are often undated and contain no indication of when they were reviewed or of the clinical disposition. Finally, we reviewed over 150 medical records and never encountered a single record with a plan of care for an inmate with special needs (e.g., inmates with chronic conditions, acute illnesses, infectious diseases and/or skin conditions, etc). 7. Inadequate Quality Improvement As noted above in the mental health section, the LCJ’s quality improvement program is poor. While the LCJ has begun quarterly quality management meetings, the LCJ has no quality management plan and has no set performance measures regarding access and quality of medical care. The Department of Health conducts quarterly reviews of ten medical records; these reviews have found problems similar to the aforementioned lack of comprehensive health assessments, chronic care clinics, and insufficient psychiatric attention. D. FIRE SAFETY AND SANITATION The Constitution grants inmates the right to reasonably sanitary and safe living conditions. Farmer 511 U.S. at 832; Vinning-El, 482 F.3d at 924-25. Our

- 21 investigation revealed that the LCJ’s fire safety and sanitation programs fall below the minimum constitutionally required standards of care. Particularly, we found constitutionally inadequate the LCJ’s: (1) fire safety; (2) housing and maintenance; (3) housekeeping; (4) laundry service; and (5) food service. These deficient practices cause inmate harm and create an unreasonable risk of harm.
1. Inadequate Fire Safety Inadequate fire safety at LCJ presents a grave risk of harm from smoke, fire, and the serious security concerns that arise during an emergency. We found no active fire safety program at the LCJ. The LCJ could not produce any fire drill logs. As detailed in the inadequate laundry service section below, we observed fire extinguishers in the laundry building that no one had inspected for at least ten years. For other LCJ areas, fire extinguisher inspections were spotty and inconsistent. We witnessed an automated cell block locking mechanism fail to work, which demonstrates that the LCJ needs to have pre-prepared reliable alternate life safety measures when these normal procedures fail. Thus, LCJ staff need readily accessible emergency keys that, according to fire codes, staff can easily identify by both sight and touch. The set of emergency keys we observed were not marked for identification by touch. 2. Inadequate Housing and Maintenance Maintenance problems permeated throughout the housing units and covered a wide range of deficiencies. We observed that shower walls and ceilings were in poor repair, shower control valves did not function properly, if at all. For example, in a 32 bed housing unit (3-C), only one of four showers functioned. In the Geriatric Unit, only one of three showers worked. We also found uncovered light switches in shower rooms, which exposed inmates to live electrical wires in a wet environment. We observed numerous totally or partially-blocked floor drains, and stopped-up and inoperable sinks. These plumbing issues generally existed throughout the LCJ. While we found ventilation generally satisfactory, we did observe supply ducts that were either plugged with paper or had heavy accumulations of dust or debris that inhibited the air movement through the housing units. For example, a significant amount of dust blocked the exhaust duct grates in the Intake Center, effectively blocking air movement through the cells. We found many mattresses and pillows that were torn or worn beyond their ability to be cleaned and disinfected between users. These deteriorated mattresses cause security problems, because inmates can easily conceal contraband under the mattress cover, and they create a risk of disease transmission because the mattresses cannot be adequately disinfected.

- 22 3. Inadequate Housekeeping LCJ’s housekeeping operations are grossly understaffed and conducted poorly. Only 1 officer and 1 civilian worker cover housekeeping duties for the entire jail; they supervise approximately 50 inmate workers. The LCJ also charges the housekeeping officer with responsibility for re-supplying control rooms, and maintaining adequate cleaning supplies in each janitor's closet. The LCJ fails to properly control chemicals. The LCJ essentially fails to supervise all inmate workers’ use of chemicals. No uniform mixing system for chemicals exists. For example, inmate workers use pine cleaner for cleaning the “old jail.” The LCJ fails to supervise these inmates’ dilution of this pine cleaner before these inmates take the chemical to the floors. Moreover, the LCJ generally leaves chemical closets unsecured specifically to enable inmate workers to go in and out at will. Beyond being a cleaning safety hazard, inmates could potentially fashion these chemicals into a weapon. Beyond this inmate access problem, we found that the LCJ fails to properly label chemicals. Jails must properly label chemicals, whether the chemicals are in the original container or not. We frequently found ready-to-use spray bottles with cleaning chemicals that were mislabeled or not labeled at all. Any chemical that has a caution, danger, or warning label must have a material safety data sheet (“MSDS”) wherever the LCJ chooses to store the chemical. Most jails typically keep these MSDS in an organized binder or folder so that staff can easily access the sheets in emergencies. We could not locate any MSDS's at the LCJ, and the housekeeping officer was not even aware of them. He also indicated that LCJ does not maintain a master list of all chemicals the LCJ uses. Nor does the LCJ maintain a running inventory of chemicals used in the LCJ. Without this inventory, the LCJ cannot account for its use of chemicals. As a result, we found inmates who were hoarding chemicals in their cells because they never knew when they would get cleaning supplies for their cells. The LCJ fails to provide adequate supplies to the inmates for cell cleaning. The housing officer stated that he puts cleaning supplies into the housing units one time per week, but that he had not done so in the last two weeks. He also stated, “it’s up to them what they do with it.” Regarding procedures for cleaning sinks, staff reported that “if inmates want to take a hand towel and dip it in the mop bucket and clean the sink, that's okay to do.” While the LCJ can use inmates to help with sanitation tasks, the LCJ needs to ensure proper procedures and supervision of these inmates. No policy or procedure regarding housekeeping duties and schedules appears to exist. Staff put mop buckets into the housing areas for floor mopping each

- 23 morning. Showers and toilets are cleaned only once a week. We found showers in the female intake and dress-out areas especially unsanitary. We observed feces and a used tampon on the shower floor in the dress-out area, and the walls were in bad condition with peeling paint and what appeared to be mold growth. Generally throughout the LCJ, we found what appeared to be mold and mildew prevalent in the shower areas. Trash and other debris clog drains. Moreover, the LCJ’s inadequate housekeeping practices have enabled drain flies to infest several floor drains.
The LCJ also documents housekeeping with logs that were extremely inconsistent or non-existent. According to the housing officer, the LCJ does not conduct regular inspections for quality assurance purposes, and has no quality assurance policies and procedures in place.
Housing Unit 3-C merits special mention. This unit stood, by far, as the worst of the housing units. The electric unlocking system was dysfunctional and staff had to manually unlock cell doors. We found three showers and one toilet were broken. Sinks were stopped up and the ceiling needed repair. Inmates in 3-C complained about their inability to get cleaning supplies on a regular basis. They also indicated that they washed their clothes in the toilet, rather than sending them to the facility laundry.
4. Inadequate Laundry Service Adequate laundry operations are essential to a sanitary jail environment. According to the LCJ inmate handbook, inmate clothing and bedding are laundered weekly upon request and blankets are exchanged monthly. Interviews with both inmates and staff revealed that the LCJ does not enforce the laundry policy’s services and schedules. One officer stated that inmates had discretion about what laundry to send on collection day. With this discretion, many inmates refuse to send their items to the laundry and will wash their personal clothing in their cells, using sinks, toilets, or showers. We observed, and several LCJ inmates indicated, that inmates laundered their clothing in toilets and sinks. Several inmates indicated that the LCJ had not washed their blankets in six months or longer. These laundry practices create an unacceptable risk that disease causing pathogens can survive and be passed from inmate to either inmate or staff. Beyond this inadequate enforcement of laundry policy, the LCJ’s laundry center is unsanitary and contains fire hazards. The LCJ uses laundry carts to transport both clean and soiled laundry to the LCJ without disinfecting them between uses. We observed gross amounts of dust and dirt throughout the center.

- 24 We also found serious fire risks in this laundry center. Statistically, more jail fires occur in laundry areas than in any part of the jail. We found heavy accumulations of dust on top of dryers, which use gas burners, creating a severe fire hazard. The most recent fire extinguisher inspection tag that we observed in the laundry dated back to 1999. Another extinguisher located near the electrical panel box indicated a very low pressure that made the extinguisher virtually useless. The tag had deteriorated so badly that we could not read the date on it. Another extinguisher located in the basement near the compressor room had a 1997 tag and had lost adequate pressure. 5. Inadequate Food Service The LCJ fails to properly track or document food service, provides inadequate meals, and uses a kitchen with numerous health and safety violations. The LCJ feeds inmate workers in a common dining room and all other inmates in their housing areas. The food service director indicated that the LCJ makes out a menu list weekly, but that this menu includes only the evening meal. The only menus that the LCJ could provide dated back to the summer and fall of 2007. No records of a qualified dietician approving menus for nutritional analysis were produced. Menu substitutions are not tracked. Inmates and the food service director confirmed that inmates held in the intake area only got cold bag meals. Some inmates are held in this area for 48 hours or longer. Several inmates in the female intake unit (H-7) reported being housed there for more than a week. Our tour of the kitchen revealed numerous health violations. The kitchen had only one hand wash sink, and access to the sink was blocked. We also found inadequately cleaned equipment, inoperable lights, and unsecured tools. Only knives are kept under lock and key, and the food supervisor could not say when inventory counts were conducted. For security purposes, the LCJ should secure all knives, utensils, and instruments, including table-mounted can openers.

- 25 III. MINIMUM REMEDIAL MEASURES In order to rectify the identified deficiencies and protect the constitutional rights of inmates confined at LCJ, the LCJ should implement, at a minimum, the following remedial measures: A. Suicide Prevention a. Rewrite policies and procedures for suicide prevention and management with the duties reassigned to appropriately licensed and credentialed staff. b. Institute direct physical observation of persons on suicide watch, rather than the current practice of custody staff watching multiple inmates on multiple camera monitors. c. Institute an adequate suicide risk assessment instrument or form that a qualified mental health professional completes prior to an inmate’s placement on suicide watch, and again prior to release from suicide watch or precaution. d. Administer prescription medications on a directly-observed basis for each dose, (unless the physician’s order notes that the inmate can self-administer the medication). Ensure accurate documentation of the medication administration, without inaccurately documenting for future doses. e. Ensure proper follow-up care for inmates with a known history of suicide watch or precaution protocols. Include documentation of comprehensive multidisciplinary treatment planning for those inmates. f. Ensure suicide watch cells are suicide-resistant (e.g., suicide resistant vents). B. Mental Health Care 1. Staffing a. Enhance staffing to meet the demands for timely access to an appropriate mental health professional.

- 26 b. Ensure qualified mental health staff perform intake mental
health screenings and evaluations. c. Ensure adequate staff to perform comprehensive assessments
and comprehensive multidisciplinary treatment planning. d. Ensure mental health staff collaborate with appropriate medical
staff. e. Verify mental health staff have appropriate credentials. 2. Intake and Referral Process a. Ensure qualified mental health staff preform the intake and
referral process. b. Ensure inmates who show positive answers on suicide
prevention screening are routinely referred to mental health. c. Change the current “crisis response” mental health care model
to a system that proactively identifies inmates who are in need of treatment or at risk of harm. d. Ensure collaboration with medical and custody staff in those areas that overlap, such as intake assessments, confidentiality for interviews, suicide prevention and management, and treatment planning. 3. Sick call a. Provide inmates with a sufficient number of sick call request forms. b. Ensure appropriate staff pick up and evaluate sick call slips at least five days per week. Triage slips for emergent conditions. c. Ensure slips are adequately logged and tracked. d. Institute quality improvement system for adequacy of the sick call process.

4. Treatment Planning

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a. Ensure adequate and appropriate treatment planning, which includes comprehensive multidisciplinary treatment team conferences. This team should include medical, nursing, and custody staff, and the inmate.

b. Institute appropriate individual therapy or group therapy, rather than the current psychosocial “contact” and “rounds.”

c. Ensure mental health records contain problem lists that allow the reader to quickly ascertain for what condition a specific inmate is being treated, including medical problems.

5. Medication Management

a. Prevent nurses from improperly writing and discontinuing medical orders without specific direction from a physician.

b. Administer prescription medications on a directly-observed basis for each dose, (unless the physician’s order notes that the inmate can self-administer the medication). Ensure accurate documentation of the medication administration, without inaccurately documenting for future doses.

6. Quality Improvement and Quality Management Program

a. Institute effective quality improvement and quality management policies and procedures. These policies and procedures should address:

i.

effectiveness of the intake assessment, referral, and sick

call process;

ii. management and utilization of psychotropic medications;

iii. suicide prevention, including assessment of suicide risk, review and tracking of suicide attempts, monitoring of inmates on suicide observations or precautions;

iv. appropriate physical plant facilities such as safe cells for management of at risk inmates, and follow-up and

- 28 treatment for those who may have engaged in suicidal or self-harm activities; v. appropriate treatment planning and treatment interventions for inmates in the mental health program; vi. discharge planning for the effective management and continuity of care for inmates leaving the system; and vii. review and audits of medical records for quality and appropriateness of documentation. b. Ensure quality improvement committee meets on a monthly basis and that this committee includes representatives from medical, mental health, and custody staff. C. Medical Care 1. Staffing a. Ensure that health care structure is organized with clear lines of authority for operations. b. Clarify training and supervision. Ensure oversight includes performance monitoring of access to care and quality of care. Ensure accountability of staff and contractors for access and quality of care. c. Enhance staffing to meet the demands for timely access to an appropriate health professional, including physicians, psychiatrists, and mid-level practitioners. d. Provide an inmate handbook to each incoming inmate. 2. Access to Medical Care a. Institute effective sick call process. See Mental Health Care remedies outlined in Section III.B.3. b. Decrease missed appointments. Document reasons for missed appointments.

- 29 c. Ensure medical records adequately document sick call with
appropriate and legible progress notes. Ensure appropriate follow-up care.

d. Ensure dental hours accommodate the need for dental care.

e. Ensure physician and mid-level staffing hours accommodate patient needs.

f. Ensure physicians adequately supervise nurses.

g. Revise co-pay system in terms of amount and waivers.

h. Ensure better confidentiality of medical examinations.

i.

Ensure medical records document all appropriate medical

information.

j.

Track and appropriately treat patients with skin infections.

k. Maintain a clean and safe environment in the medical areas, including the proper handling of waste, biohazards, sharps, chemicals, and medications.

3. Acute and Chronic Medical Care

a. Ensure timely access to appropriate care, including physician evaluations and prescribed medications, for inmates with acute medical problems. Ensure adequate acute follow-up care.

b. Take and document vital signs of inmates with acute medical conditions, including withdrawal from alcohol and other substances.

c. Adequately manage inmates with chronic conditions in a chronic care clinic that adequately identifies, tracks, treats, and monitors such inmates.

d. Appropriately document chronic care in medical records.

- 30 4. Comprehensive Health Assessments
a. Provide a comprehensive health evaluation to all inmates and juveniles within 14 days of booking that includes vital signs, a comprehensive medical history, and, for juveniles, immunization records.
5. Medication Administration a. Secure the medication room. Discontinue allowing food in the medication refrigerator. b. Prevent nurses from discontinuing medications without a physician’s order. Ensure that a prescribing practitioner counsels all patients who refuse medication. c. Administer prescription medications on a directly-observed basis for each dose, (unless the physician’s order notes that the inmate can self-administer the medication). Ensure accurate documentation of the medication administration, without inaccurately documenting for future doses. d. Abolish standing orders for non-emergency medication. Stop nurses from inaccurately documenting medication orders as being ordered via telephone. e. Ensure nurses practice within the scope of their licensures. f. Create some formal mechanism, such as a Pharmacy and Therapeutics Committee, to assist in creating guidelines for the prescription of certain types of medications.
6. Medical Records a. Ensure the uniformity and organization of medical records. Institute the use of a problem-oriented format with problem lists and SOAP format notes. b. Ensure nursing staff record the date and disposition of all requests for medical care. c. Ensure clinical notes are entered into the medical record and are legible.

- 31 d. Ensure an up-to-date, legible, treatment plan for patients with
special needs, including chronic conditions, acute illnesses, and infectious diseases and skin conditions. 7. Quality Improvement a. Develop a quality management plan that addresses the medical deficiencies, sets forth performance criteria, conducts data analysis (both quantitative and qualitative), and implements corrective measures to improve performance. D. Sanitation and Fire Safety 1. Fire Safety a. Institute an active fire safety program. b. Improve fire drill logs documentation. c. Ensure timely regular inspection of all fire extinguishers. d. Ensure staff have readily accessible emergency keys that staff can easily identify by both sight and touch. 2. Housing and Maintenance a. Address maintenance problems with damaged or inoperable showers, toilets, drains, and sinks. Cover all light switches with exposed wires. b. Clear air supply ducts. c. Ensure proper air temperatures in cell blocks and that inmates have appropriate access to blankets. d. Ensure all mattresses and pillows are not damaged to the point where they cannot be properly cleaned and disinfected between users. 3. Housekeeping a. Ensure adequate numbers of staff to perform housekeeping duties.

- 32 -
b. Ensure proper control of chemicals, including supervision of inmate workers handling chemicals, uniform chemical mixing systems, secure chemical storage, proper chemical labeling, and accessible MSDS sheets.
c. Institute a master list of all chemicals the LCJ uses and maintain a running inventory of these chemicals.
d. Provide inmates adequate supplies for cell cleaning. e. Institute a policy regarding housekeeping duties and schedules. f. Improve housekeeping documentation. g. Institute quality assurance policies and procedures. 4. Laundry Service a. Improve enforcement of laundry policy to ensure that inmates
send their laundry to the laundry service facility rather than washing their laundry in their cells. b. Ensure inmates’ clothing is laundered at least weekly. c. Ensure blankets are laundered at least monthly or between uses by different inmates. d. Improve the laundry facility’s unsanitary environment and fire safety hazards. 5. Food Service a. Properly track and document food service. b. Provide inmates adequate meals. c. Eliminate kitchen’s health and safety violations, including unlocked access to knives, utensils, and instruments, including table-mounted can openers.
* * * * * * *

- 33 Please note that this findings letter is a public document. We will post it on the Civil Rights Division’s website. While we will provide a copy of this letter to any individual or entity upon request, as a matter of courtesy, we will not post this letter on the Civil Rights Division’s website until ten calendar days from the date of this letter. We hope to continue working with the County in an amicable and cooperative fashion to resolve our outstanding concerns regarding the LCJ. Assuming the present spirit of cooperation from Lake County is continuing, we also are willing to send our consultants’ evaluations under separate cover. These reports are not public documents. Although the consultants’ evaluations and work do not necessarily reflect the official conclusions of the Department of Justice, their observations, analysis, and recommendations provide further elaboration on the issues discussed in this letter and offer practical technical assistance in addressing them. CRIPA obligates us to advise you that, in the event that we are unable to reach a resolution regarding our concerns, the Attorney General may initiate a lawsuit pursuant to CRIPA to correct deficiencies of the kind identified in this letter 49 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 are confident that we will be able to do so in this case. The lawyers assigned to this investigation will be contacting the LCJ’s attorney to discuss this matter in further detail. If you have any questions regarding this letter, please call Shanetta Y. Cutlar, Chief of the Civil Rights Division’s Special Litigation Section, at (202) 514-0195.
Sincerely,
/s Thomas E. Perez Thomas E. Perez Assistant Attorney General

cc: Roy Dominguez Lake County Sheriff

- 34 -

John S. Dull County Commissioner Attorney

David A. Capp United States Attorney Northern District of Indiana

John Kopack Attorney for Sheriff Dominguez

 
 USDC IN/ND case 2:10-cv-00476-TLS-PRC document 77 filed 12/18/19 page 1 of 2

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF INDIANA
HAMMOND DIVISION

UNITED STATES OF AMERICA,

Plaintiff,

v.

CAUSE NO.: 2:10-CV-476-TLS

LAKE COUNTY, INDIANA, et al.,

Defendants. ORDER
This matter is before the Court on the Joint Motion to Terminate Settlement Agreement and For Final Dismissal [ECF No. 74], filed on December 17, 2019. For the reasons stated below, the Court grants this request.
On December 3, 2010, the United States of America filed a Complaint [ECF No. 1] in which it alleged that the Defendants were deliberately indifferent to the health and safety of inmates at the Lake County Jail (LCJ). See Compl. ¶ 26. On December 20, 2010, the Court (1) approved a Joint Settlement Agreement [ECF No. 9] which established guidelines for the Defendants to follow and (2) retained jurisdiction to ensure the timely and proper implementation of the agreement. Order, ECF No. 12. The agreement provided that it “shall terminate when LCJ has achieved substantial compliance with the substantive provisions of this Agreement and has maintained that substantial compliance for one (1) year.” Settlement Agreement, p. 28, ECF No. 9.
On December 17, 2019, the parties filed the instant Joint Motion to Terminate Settlement Agreement in which they agreed that “Lake County has reached substantial compliance with the terms of the Agreement in its entirety and termination is appropriate under Section V.3.(a) of the

USDC IN/ND case 2:10-cv-00476-TLS-PRC document 77 filed 12/18/19 page 2 of 2 Agreement.” Joint Mot. to Terminate Settlement Agreement, p. 6. The Court has reviewed the record and finds that the requested relief is appropriate. Therefore, the parties’ joint motion is granted.
CONCLUSION For the reasons stated above, the Court GRANTS the Joint Motion to Terminate Settlement Agreement and For Final Dismissal [ECF No. 74]. The Court ORDERS that the Settlement Agreement [ECF No. 9] is TERMINATED. The Court RELINQUISHES its continuing jurisdiction and DISMISSES this case. SO ORDERED on December 18, 2019.
s/ Theresa L. Springmann CHIEF JUDGE THERESA L. SPRINGMANN UNITED STATES DISTRICT COURT
2

 
 USDC IN/ND Case: 2:10-cv-476 As of: 05/11/2020 01:00 AM EDT 1 of 7 CASREF,TERMED
U.S. District Court Northern District of Indiana [LIVE] USDC Northern Indiana (Hammond)
CIVIL DOCKET FOR CASE #: 2:10−cv−00476−TLS−PRC

United States of America v. Lake County Indiana et al Assigned to: Chief Judge Theresa L Springmann Referred to: Magistrate Judge Paul R Cherry Cause: 42:1997 Civil Rights of Institutionalized Persons Act
Plaintiff

Date Filed: 12/03/2010 Date Terminated: 12/20/2010 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by William G Maddox US Department of Justice − Was/DC/601/5018 Civil Rights Division Special Litigation Section 601 D St NW Rm 5018 PHB Bldg Washington, DC 20004 202−514−6251 Fax: 202−514−0212 Email: william.maddox@usdoj.gov ATTORNEY TO BE NOTICED

V. Defendant Lake County Indiana

represented by John M Kopack John M Kopack & Associates 9111 Broadway Ste GG PO Box 10607 Merrillville, IN 46411 219−738−2978 Fax: 219−738−2818 Email: john@kopack−law.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Patricia Roman Hass Reminger Co LPA − CP/IN One Professional Center 2100 N Main St Ste 202 Crown Point, IN 46307 219−663−3011 Fax: 219−663−1049 Email: promanhass@reminger.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
John P Bushemi Burke Costanza & Carberry LLP − Mer/IN 9191 Broadway Merrillville, IN 46410 219−769−1313 Fax: 219−769−6806 Email: bushemi@bcclegal.com TERMINATED: 03/15/2018
Michael J Bolde Kenneth J Allen Law Group − Val/IN 1109 Glendale Blvd Valparaiso, IN 46383

USDC IN/ND Case: 2:10-cv-476

As of: 05/11/2020 01:00 AM EDT 2 of 7 219−227−6077 Fax: 219−227−6101 Email: mbolde@allen.law TERMINATED: 03/01/2016

Defendant
Rogelio Roy Dominguez Lake County Sherriff in his official capacity only

represented by John P Bushemi (See above for address) TERMINATED: 08/15/2011 LEAD ATTORNEY ATTORNEY TO BE NOTICED

John M Kopack (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Patricia Roman Hass (See above for address) TERMINATED: 08/15/2011 LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant
Frances DuPey President, Lake County Board of Commissioners, in her official capacity only

represented by John S Dull Law Office of John S Dull PC PO Box 14058 Merrillville, IN 46411 219−644−7172 Fax: 219−648−6138 Email: jsdull@yahoo.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant
Thomas C O'Donnell President, Lake County Council, in his official capacity only

represented by Gerald M Bishop Gerald M Bishop & Associates 2115 W Lincoln Highway Merrillville, IN 46410 219−738−2400 Fax: 219−738−2500 Email: gmb@bishop−law.com ATTORNEY TO BE NOTICED

Defendant
Lake County Board of Commissioners in their official capacity only

represented by John S Dull (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED

Matthew N Fech Law Office of Matthew N Fech PC 219 N Broad St Griffith, IN 46319 219−228−8374 Fax: 219−979−5319 Email: mnf@fech−law.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Defendant

represented by

USDC IN/ND Case: 2:10-cv-476 As of: 05/11/2020 01:00 AM EDT 3 of 7

Lake County Council

Gerald M Bishop

in their official capacity only

(See above for address)

ATTORNEY TO BE NOTICED

Date Filed 12/03/2010 12/03/2010 12/03/2010 12/03/2010 12/03/2010 12/03/2010
12/03/2010
12/03/2010 12/03/2010
12/15/2010
12/20/2010
12/20/2010
08/04/2011 08/04/2011 08/04/2011 08/10/2011

# Docket Text
1 COMPLAINT filed by United States of America AGAINST All Defendants. (Attachments: # 1 Civil Cover Sheet)(jjj) (Entered: 12/06/2010)
2 NOTICE of Appearance by Gerald M Bishop on behalf of Thomas C O'Donnell. (jjj) (Entered: 12/06/2010)
3 NOTICE of Appearance by John S Dull on behalf of Frances DuPey. (jjj) (Entered: 12/06/2010)
4 NOTICE of Appearance by John M Kopack on behalf of Rogelio Roy Dominguez, Lake County Indiana. (jjj) (Entered: 12/06/2010)
5 NOTICE of Appearance by William G Maddox on behalf of United States of America. (jjj) (Entered: 12/06/2010)
6 WAIVER OF SERVICE Returned Executed by United States of America. Thomas C O'Donnell waiver sent on 12/3/2010. Answer due 2/1/2011. Lake County Council waiver sent on 12/3/2010. Answer due 2/1/2011. (jjj) Modified to reflect executed by on 12/6/2010 (jjj). (Entered: 12/06/2010)
7 WAIVER OF SERVICE Returned Executed by United States of America. Frances DuPey waiver sent on 12/3/2010. Answer due 2/1/2011. Lake County Board of Commissioners waiver sent on 12/3/2010. Answer due 2/1/2011. (jjj) (Entered: 12/06/2010)
8 WAIVER OF SERVICE Returned Executed by United States of America. Rogelio Roy Dominguez waiver sent on 12/3/2010. Answer due 2/1/2011. Lake County Indiana waiver sent on 12/3/2010. Answer due 2/1/2011. (jjj) (Entered: 12/06/2010)
9 JOINT MOTION TO ENTER SETTLEMENT AGREEMENT by Plaintiff United States of America AND Defendants Rogelio Roy Dominguez, Frances DuPey, Lake County Board of Commissioners, Lake County Council, Lake County Indiana, and Thomas C O'Donnell. (jjj) (Entered: 12/06/2010)
10 ORDER FOR JUDGE THERESA L SPRINGMANN. The Court SETS a Telephonic Status Conference set for 12/20/2010 at 11:00 AM (Fort Wayne time) before Judge Theresa L Springmann re 9 MOTION for Settlement. The Court will initiate the call.(jw) (Entered: 12/15/2010)
11 TELEPHONE STATUS CONFERENCE held before Judge Theresa L Springmann. USA appeared by atty William Maddox. Dfts Rogelio Roy Dominguez, Lake County Indiana appeared by atty John Kopack. Dfts Frances DuPey, Lake County Board of Commissioners appeared by atty John Dull. Dfts Lake County Council and Thomas C O'Donnell atty Gerald Bishop unable to participate. Parties confirm settlment agreement is properly approved by Dft Lake County Board of Commissioners. (Tape #20 FTR Gold.) (jw) (Entered: 12/20/2010)
12 ORDER granting 9 Motion for Settlement and APPROVING the Settlement Agreement in its entirety. The court shall retain jurisdiction over this matter to ensure timely and proper implementation of the Settlement Agreement. Signed by Judge Theresa L Springmann on 12/20/10. (mc) (Entered: 12/21/2010)
13 NOTICE of Appearance by John P Bushemi on behalf of Rogelio Roy Dominguez (Bushemi, John) (Entered: 08/04/2011)
14 NOTICE of Appearance by Patricia Hass on behalf of Rogelio Roy Dominguez (Hass, Patricia) (Entered: 08/04/2011)
15 REPORT by Rogelio Roy Dominguez. (Bushemi, John) (Entered: 08/04/2011)
16 ORDER FOR JUDGE THERESA L SPRINGMANN: Telephonic Status Conference SET for 8/29/2011 02:30 PM in US District Court − Fort Wayne before Judge Theresa

USDC IN/ND Case: 2:10-cv-476 As of: 05/11/2020 01:00 AM EDT 4 of 7 L Springmann re 15 Report filed by Rogelio Roy Dominguez. Court will initiate call. (jjj) cc William Maddox (Entered: 08/10/2011)

08/10/2011 17 MOTION to Withdraw Appearance by Defendant Rogelio Roy Dominguez. (Bushemi, John) (Entered: 08/10/2011)

08/10/2011 18 MOTION to Withdraw Appearance by Defendant Rogelio Roy Dominguez. (Hass, Patricia) (Entered: 08/10/2011)

08/10/2011 19 NOTICE of Appearance by John P Bushemi on behalf of Lake County Indiana (Bushemi, John) (Entered: 08/10/2011)

08/10/2011 20 NOTICE of Appearance by Patricia Hass on behalf of Lake County Indiana (Hass, Patricia) (Entered: 08/10/2011)

08/15/2011

21 ORDER granting 17 and 18 Motion to Withdraw Appearance. The appearance of Attorneys John P. Bushemi and Patricia Hass are WITHDRAWN as counsel for Defendant Dominguez. Signed by Magistrate Judge Paul R Cherry on 8/15/11. (mc) (Entered: 08/16/2011)

08/29/2011

22 TELEPHONE CONFERENCE held before Judge Theresa L Springmann. Pla appeared by atty William Maddox. Dft appeared by attys John Bushemi, John Kopack, and Patricia Hass. Court unable to reach Dfts' attys John Dull and Gerald Bishop. Parties as to case status. Court to receive compliance report within approximately 6 months. Telephonic Status Conference set for 3/15/2012 02:30 PM in US District Court − Fort Wayne before Judge Theresa L Springmann. Court will initiate call. (Court Reporter FTR.) (jjj) cc William Maddox (Entered: 08/30/2011)

09/22/2011

23 Mail Returned as Undeliverable (NEF of Order dated 8/10/11, DE 16 ). Mail sent to William G Maddox; envelope marked "Return to Sender, Not in Criminal Section". (cer) (Entered: 09/22/2011)

01/18/2012 24 STATUS REPORT Second Compliance Report by United States of America. (Maddox, William) (Entered: 01/18/2012)

03/15/2012

25 TELEPHONE CONFERENCE held on 3/15/2012 before Judge Theresa L Springmann. Pla appeared by atty William Maddox. Dft appeared by atty John Bushemi, John Kopack, Patricia Hass, John Dull, and Gerald Bishop. Parties advise next compliance report to be filed with Court by the end of July 2012. (Court Reporter FTR.) (jjj) (Entered: 03/15/2012)

07/25/2012 26 REPORT by United States of America Third Compliance Report. (Maddox, William) (Entered: 07/25/2012)

07/31/2012

27 ORDER FOR JUDGE THERESA L SPRINGMANN: Telephonic Status Conference SET for 8/23/2012 03:30 PM EASTERN TIME in US District Court − Fort Wayne before Judge Theresa L Springmann re 26 Report filed by United States of America. Court will initiate call. (jjj) (Entered: 07/31/2012)

08/23/2012

28 TELEPHONIC STATUS CONFERENCE held before Judge Theresa L Springmann. Pla appeared by atty William Maddox. Dft appeared by attys John Kopack, John Dull, Gerald Bishop and John Bushemi with Ken Ray, Compliance Consultant. Parties advise next compliance report to be filed with Court by the end of 1/2013. Court to schedule telephone status conference if report not filed. (Court Reporter FTR.) (cer) (Entered: 08/23/2012)

01/22/2013 29 REPORT by United States of America Fourth Compliance Report. (Maddox, William) (Entered: 01/22/2013)

02/05/2013 30 REPORT by United States of America Fourth Compliance Report. (Attachments: # 1 Exhibit Fourth Compliance Report)(Maddox, William) (Entered: 02/05/2013)

02/05/2013

31 ORDER: the Court acknowledges receipt of the Compliance Report and has reviewed its contents. The Court anticipates receiving the next status report prior to July 31, 2013. Signed by Judge Theresa L Springmann on 2/5/13. (mc) (Entered: 02/05/2013)

08/26/2013

32 ORDER FOR JUDGE THERESA L SPRINGMANN: Telephonic Status Conference SET for 9/18/2013 03:00 PM (Eastern time) in US District Court − Fort Wayne before Judge Theresa L Springmann re 31 ORDER re status report. Court will initiate call.

USDC IN/ND Case: 2:10-cv-476 As of: 05/11/2020 01:00 AM EDT 5 of 7 (jjj) (Entered: 08/26/2013)

08/28/2013 33 MOTION to Reschedule Telephonic Status Conference by Defendant Lake County Indiana. (Bushemi, John) (Entered: 08/28/2013)

09/11/2013

34 ORDER FOR JUDGE THERESA L SPRINGMANN: On the Court's own motion, the telephone conference set on 9/18/2013 is VACATED. The 33 MOTION to Reschedule Telephonic Status Conference is RENDERED MOOT. Parties are ORDERED by 10/11/2013 to file a JOINT status/complaince report. (jjj) (Entered: 09/11/2013)

09/13/2013 35 NOTICE of Appearance by Michael J Bolde on behalf of Lake County Indiana (Bolde, Michael) (Entered: 09/13/2013)

09/30/2013 36 NOTICE by United States of America Fifth Compliance Report (Attachments: # 1 Exhibit Fifth Compliance Report)(Maddox, William) (Entered: 09/30/2013)

09/30/2013

37 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 36 COMPLIANCE REPORT (Fifth) filed by United States of America. Parties are ORDERED by 4/4/2014 to file a JOINT status/compliance report. (jjj) (Entered: 09/30/2013)

04/29/2014

38 ORDER FOR JUDGE THERESA L SPRINGMANN: The joint status/compliance report ddl of 4/4/2014 has passed and parties have failed to notice the Court re 37 ORDER. Parties have up to 5/9/2014 to file a JOINT status compliance report as previously directed. (jjj) (Entered: 04/29/2014)

04/30/2014 39 NOTICE by United States of America (Attachments: # 1 Exhibit Sixth Compliance Report)(Maddox, William) (Entered: 04/30/2014)

05/02/2014

40 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 39 COMPLIANCE REPORT (Sixth) filed by United States of America. Parties are ORDERED by 11/17/2014 to file a JOINT status/compliance report. (jjj) (Entered: 05/02/2014)

10/10/2014 41 STATUS REPORT Seventh Status Report by United States of America. (Attachments: # 1 Exhibit Seventh Status Report)(Maddox, William) (Entered: 10/10/2014)

10/15/2014

42 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 41 COMPLIANCE REPORT (Seventh) filed by United States of America. Parties are ORDERED by 4/17/2015 to file a JOINT status/compliance report. (jjj) (Entered: 10/15/2014)

02/17/2015

43 (WITHDRAWN SEE 45 ) MOTION to Terminate Forty−Two (42) Provisions of Settlement Agreement in Sustained Compliance by Defendant Lake County Indiana. (Bushemi, John) Modified on 3/6/2015 (rmn). (Entered: 02/17/2015)

02/25/2015

44 MOTION to Withdraw 43 MOTION to Terminate Forty−Two (42) Provisions of Settlement Agreement in Sustained Compliance by Defendant Lake County Indiana. (Bushemi, John) (Entered: 02/25/2015)

03/06/2015

45 ORDER: GRANTS the Defendants Motion 44 and ORDERS the Defendants Motion to Terminate Forty−Two (42) Provisions of Settlement Agreement in Sustained Compliance 43 WITHDRAWN. Signed by Judge Theresa L Springmann on 3/6/2015. (rmn) (Entered: 03/06/2015)

04/10/2015

46 STATUS REPORT Eighth Compliance Report by United States of America. (Attachments: # 1 Exhibit Eighth Status Report)(Maddox, William) (Entered: 04/10/2015)

04/14/2015

47 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 46 Status Report Eighth Compliance Report filed by United States of America. Parties are ORDERED by 10/16/2015 to file a JOINT Status/Compliance report. Signed by Judge Theresa L Springmann on 4/14/2015. (jlb) (Entered: 04/14/2015)

09/17/2015

48 MOTION Joint Motion to Terminate Subsection D. Fire Safety of the Settlement Agreement in Sustained Compliance by Defendant Lake County Indiana. (Bushemi, John) (Entered: 09/17/2015)

09/30U/2S0D15C IN4/N9 DSCTaAsTeU:S2R:1E0P-OcvR-T47N6inthACsoomfp:l0ia5n/c1e1R/2ep0o2r0t b0y1U:0ni0teAd MStaEteDs Tof A6moerfic7a. (Attachments: # 1 Exhibit)(Maddox, William) (Entered: 09/30/2015)

10/01/2015

50 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 49 Status Report Ninth Compliance Report filed by United States of America. Parties are ORDERED by 4/1/2016 to file a JOINT Status/Compliance report. (jlb) (Entered: 10/01/2015)

10/06/2015

51 ORDER granting 48 Motion Joint Motion to Terminate Subsection D. Fire Safety of the Settlement Agreement in Sustained Compliance. Signed by Judge Theresa L Springmann on 10/6/15. (mc) (Entered: 10/06/2015)

02/23/2016 52 MOTION to Withdraw as Attorney by Defendant Lake County Indiana. (Bolde, Michael) (Entered: 02/23/2016)

03/01/2016

53 ORDER granting 52 Motion to Withdraw as Attorney. Attorney Michael J Bolde WITHDRAWN. Text entry order. By Magistrate Judge Paul R Cherry on 3/1/2016. (smb) (Entered: 03/01/2016)

03/18/2016 54 STATUS REPORT Tenth by United States of America. (Attachments: # 1 Tenth Status Report)(Maddox, William) (Entered: 03/18/2016)

03/25/2016

55 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 54 Status Report Tenth filed by United States of America. Parties are ORDERED by 9/30/2016 to file a JOINT Status/Compliance report. (jlb) (Entered: 03/25/2016)

09/22/2016

56 STATUS REPORT Eleventh Compliance Report by United States of America. (Attachments: # 1 Exhibit Eleventh Compliance Report)(Maddox, William) (Entered: 09/22/2016)

09/26/2016

57 ORDER FOR JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 56 Status Report Eleventh Compliance Report filed by United States of America. Parties are ORDERED by 4/1/2017 to file a JOINT Status/Compliance Report.(cer) (Entered: 09/26/2016)

03/31/2017 58 STATUS REPORT Twelfth Status Report by United States of America. (Attachments: # 1 Exhibit)(Maddox, William) (Entered: 03/31/2017)

08/10/2017

59 MOTION Joint Motion to Terminate Subsection A, Medical Care, and Subsection C, Suicide Prevention, of Settlement Agreement by Defendant Lake County Indiana. (Bushemi, John) (Entered: 08/10/2017)

08/31/2017

60 ORDER GRANTING 59 MOTION Joint Motion to Terminate Subsection A, Medical Care, and Subsection C, Suicide Prevention, of Settlement Agreement by Defendant Lake County Indiana. Signed by Chief Judge Theresa L Springmann on 8/31/2017. (lhc) (Entered: 08/31/2017)

01/19/2018

61 STATUS REPORT Thirteenth Compliance Report by United States of America. (Attachments: # 1 Exhibit Thirteenth Compliance Report)(Maddox, William) (Entered: 01/19/2018)

01/19/2018

62 STATUS REPORT Fourteenth Compliance Report and LCJ Compliance Action Plan by United States of America. (Attachments: # 1 Exhibit Fourteenth Compliance Report, # 2 Exhibit LCJ DOJSA Compliance Action Plan)(Maddox, William) (Entered: 01/19/2018)

01/19/2018

63 ORDER FOR CHIEF JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 61 Status Report Thirteenth Compliance Report and 62 Status Report Fourteenth Compliance Report and Compliance Action Plan filed by United States of America. Parties are ORDERED by 7/31/2018 to file a JOINT Status/Compliance Report. (cer) (Entered: 01/19/2018)

03/14/2018 64 MOTION to Withdraw as Attorney by Defendant Lake County Indiana. (Bushemi, John) (Entered: 03/14/2018)

03/15/2018

65 MINUTE ORDER granting 64 Motion to Withdraw as Attorney. The appearance of Attorney John P Bushemi on behalf of Defendant Lake County, Indiana, is WITHDRAWN. Text entry order. By Magistrate Judge Paul R Cherry on 3/15/2018. (mr) (Entered: 03/15/2018)

08/23U/2S0D18C IN6/N6 DOCRaDsEeR: 2F:O1R0-CcHv-I4E7F6JUDAGs EofT:H0E5R/1E1S/A20L2S0P0R1IN:0G0MAAMNNE:DOTn 17/19o/f27018, the parties were ordered to file a Joint Status/Compliance Report by 7/31/2018. To date, the parties have not responded. Accordingly, the parties are DIRECTED to file a Joint Status/Compliance Report on or before 9/6/2018.(cer) (Entered: 08/23/2018)

09/05/2018

67 STATUS REPORT Fifteenth Joint Compliance Report by United States of America. (Attachments: # 1 Exhibit Fifteenth Joint Compliance Report, # 2 Addendum Lake County Corrective Action Plan Update)(Maddox, William) (Entered: 09/05/2018)

09/06/2018

68 ORDER FOR CHIEF JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 67 Status Report Fifteenth Compliance Report filed by United States of America. Parties are ORDERED by 3/8/2019 to file a JOINT Status/Compliance Report.(cer) (Entered: 09/06/2018)

03/07/2019

69 STATUS REPORT Sixteenth Compliance Report by United States of America. (Attachments: # 1 Exhibit Sixteenth Compliance Report)(Maddox, William) (Entered: 03/07/2019)

03/07/2019

70 ORDER FOR CHIEF JUDGE THERESA L SPRINGMANN: The Court is in receipt of the 69 Status Report Sixteenth Compliance Report filed by United States of America. Parties are ORDERED by 9/9/2019 to file a JOINT Status/Compliance Report.(cer) (Entered: 03/07/2019)

09/05/2019

71 STATUS REPORT Seventeenth Compliance Report by United States of America. (Attachments: # 1 Exhibit Seventeenth Compliance Report)(Maddox, William) (Entered: 09/05/2019)

09/10/2019

72 ORDER: The Court is in receipt of the Seventeenth Compliance Report 71 for the Lake County Jail filed by United States of America. The Court SCHEDULES a telephonic status conference for 11:00 AM (C.S.T.) on 12/18/2019. Signed by Chief Judge Theresa L Springmann on 09/10/2019. (jat) (Entered: 09/10/2019)

12/08/2019

73 STATUS REPORT Eighteenth Compliance Report by United States of America. (Attachments: # 1 Exhibit 18th Compliance Report)(Maddox, William) (Entered: 12/08/2019)

12/17/2019

74 MOTION to Dismiss Joint Motion To Terminate Settlement Agreement And For Final Dismissal by Defendants Rogelio Roy Dominguez, Lake County Indiana. (Kopack, John) (Entered: 12/17/2019)

12/17/2019

75 NOTICE of Appearance by Matthew N Fech on behalf of Lake County Board of Commissioners (Fech, Matthew) ***FILING ERROR − ATTORNEY INSTRUCTED TO REFILE; ATTORNEY RE−FILED AT 78 *** Modified on 12/18/2019 (ace). Modified on 12/23/2019 (ace). (Entered: 12/17/2019)

12/17/2019

76 ORDER FOR CHIEF JUDGE THERESA L SPRINGMANN: The Court VACATES the telephonic status conference set for 12/18/2019 per the filing of 74 MOTION to Dismiss Joint Motion To Terminate Settlement Agreement And For Final Dismissal. (rs) (Entered: 12/17/2019)

12/18/2019

77 ORDER granting 74 Motion to Terminate Settlement Agreement and For Final Dismissal. The Court ORDERS that the Settlement Agreement [ECF No. 9] is TERMINATED. The Court RELINQUISHES its continuing jurisdiction and DISMISSES this case. Signed by Chief Judge Theresa L Springmann on 12/18/19. (mlc) (Entered: 12/19/2019)

12/20/2019 78 NOTICE of Appearance by Matthew N Fech on behalf of Lake County Board of Commissioners (Fech, Matthew) (Entered: 12/20/2019)