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Attachment B

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 2 of 99 PageID #:11 U.S. Department of Justice
Civil Rights Division

--
Oflee of the Assistant Attorney General

Washington,D.C.20530

JUL 1 1 2008
Todd H. Stroger Cook County Board President 118 N. Clark Street Room 537 Chicago, IL 60602
Thomas Dart Cook County Sheriff Richard J. Daley Center 50 W. Washington Street Room 704 Chicago, IL 60602
Re: Cook County Jail Chicaqo, Illinois
Dear President Stroger and Sheriff Dart:
We write to report the findings of the investigation of Civil Rights Division and the United States Attorney's Office into conditions at the Cook County Jail ('CCJ"). On February 1.6, 2007, we notified the Cook County Board of Commissioners ("County") of our intent to conduct an investigation of CCJ pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. As we noted, CRIPA gives the Department of Justice authority to.seek a remedy for a pattern or practice of conduct that violates the constitutional rights of inmates in adult detention and correctional facilities.
On June 18-22, 2007, and July 23-27, 2007, we conducted on-site inspections at CCJ with expert consultants in corrections, use of force, custodial medical and mental health care, fire safety, and sanitation.' We interviewed
1 Our fire safety and sanitation experts accompanied us only on the July on-site visit.

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administrative staff, security staff, medical and mental health staff, facilities management staff, training staff, and inmates. Before, during, and after our visits, we reviewed an extensive number of documents, including policies and procedures, incident reports, use of force reports, investigative reports, inmate grievances, disciplinary reports, unit logs, orientation materials, medical records, and staff training materials. In keeping with our pledge of transparency and to provide technical assistance where appropriate, we conveyed our preliminary findings to CCJ officials and legal counsel for the County and Sheriff's Office at the close of our July 2007 site visit.
During our July 27, 2007 exit meeting, and by letter dated August 3, 2007, we notified CCJ officials of life-threatening deficiencies in sanitation and safety measures at CCJ. In particular, we indicated that inadequate emergency key precautions and grossly unsanitary conditions in certain tiers resulted in a serious and immediate risk of harm to inmates. On August 6, 2007, counsel for the Sheriff's Office promptly responded by indicating that a number of corrective measures were being implemented to address our concerns.'
We commend the staff at CCJ for their helpful and professional conduct throughout the course of the investigation. We received complete cooperation with our investigation, which is particularly appreciated given that CCJ is the country's largest single-site jail. CCJ provided us with unfettered access to records and personnel, and responded to our requests, both before and during our on-site visits, in a transparent and forthcoming manner. We also appreciate the County's and the Sheriff's Office's receptiveness to our consultants' on-site recommendations. Accordingly, we have every reason to believe that the County and the Sheriff's Office are committed to remedying all known deficiencies at CCJ.
Consistent with the statutory requirements of CRIPA, we now write to advise you of the findings of our investigation, the facts supporting them, and the minimum remedial steps that are necessary to address the deficiencies we have identified.
2 Counsel for the Sheriff's Office provided additional information regarding corrective measures in a letter and attachments on October 5, 2007. We commend the Sheriff's Office on these reported advances and view them as progress toward improved conditions at CCJ. We look forward to the opportunity to verify the improvements.

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42 S U.S.C. 1997b. As described more fully below, we conclude that certain conditions at CCJ violate the constitutional rights of inmates. In particular, we find that inmates confined at CCJ are not adequately protected from harm, including physical harm from excessive use of force by staff and inmate-on-inmate violence due to inadequate supervision. In addition, we find that inmates do not receive adequate medical and mental health care, including proper suicide prevention. CCJ inmates also face serious risks posed by inadequate fire safety precautions. Finally, we find that environmental and sanitation deficiencies at CCJ result in unconstitutional living conditions for inmates.
As discussed in this letter, these conditions have resulted in serious harm to CCJ inmates. Three inmates committed suicide at CCJ in the first four months of 2008. During our investigation, we identified multiple preventable inmate deaths and a preventable amputation, due to inadequate medical care. In 2006, separate incidents of unchecked inmate violence resulted in two inmate deaths. In a one-week period during March 2007, CCJ documented 35 inmate fights, required 27 uses of force, and found 46 weapons within the facility. The myriad of serious incidents summarized here, and others discussed herein, indicates that CCJ is not adequately providing for the safety and well-being of the inmates.
I. BACKGROUND
Located on approximately 96 acres in Chicago, Illinois, CCJ is the largest single-site county jail in the United state^.^ CCJ has a daily population of approximately 9,800 adult male and female inmates, most of whom are awaiting trial in the criminal court system. In 2006, CCJ admitted 99,663 inmates. CCJ is staffed by approximately 3,800 sworn law enforcement officers and civilian employees.
CCJ is separated into 11 semi-autonomous divisionsI4each with its own superintendent and standard operating procedures. The majority of the male inmates are housed in three maximum-security divisions (Divisions I, IX, and X), three medium-security male divisions (Divisions V, VI, and XI), and one
4 The divisions are designated by number, one through eleven. There is no Division VII. The Receiving Classification Diagnostic Center essentially functions as a separate division, with its own superintendent.

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medium and minimum-security dormitory division (Division 11) .
Female inmates of mixed security classifications are housed on Division 111, which also contains male and female medical and mental health tiers, and Division IV. Division VIII contains Cermak Health Services and the Residential Treatment Unit. The Receiving, Classification, and Diagnostics Center ("RCDC") is located in the lower level of Division V and handles reception, classification, and discharge for all CCJ inmates. Division I is the oldest building, dating from 1929, and Division XI is the newest, opened in 1995. The divisions range in rated capacity5 from 353 inmates in Division I11 to 1,536 in Division XI.
All corrections and security functions at CCJ are administered by the Cook County Department of Corrections ("CCDOC") under the Cook County Sheriff. Health care services at CCJ are provided by Cermak Health Services of Cook County ("Cermak"), which is part of the Cook County Bureau of Health. While the health services staff are County employees who are responsible for the health care of all CCJ inmates, they are not
employed by, or responsible to, the Cook County Sheriff or CCDOC. .
Although health care and security issues require a degree of separation in all correctional facilities, as discussed in more detail below, the complete division between corrections and health care operations at CCJ results in serious administrative problems, including increased frustration, communication breakdowns, and finger-pointing. Regardless of the administrative division, Cook County and the Cook County Sheriff's Office are responsible for the well-being of CCJ inmates, including providing adequate care for inmates' serious medical and mental health care needs.
In 1982, the 'County entered into a consent decree i n Duran v. Dart, No. 74-C-2949 (N.D. Ill. Apr. 9, 1982) ('Duran Consent Decree") to resolve a class action lawsuit filed by pre-trial detainees, pursuant to 42 U.S.C. § 1983, regarding overcrowding of CCJ. The Duran Consent Decree, as amended, is still under the jurisdiction of the United States District Court for the Northern District of Illinois. The decree focuses on overcrowding, but does contain some provisions governing staffing, food service, personal hygiene, the law library, visitation, physical exercise, classification, environmental health, and emergencies. CCJ1s compliance with the Duran Consent Decree is monitored by the John Howard Association. CCJ is also governed by multiple other
5 Actual capacity is often much lower than the rated capacity due to cells that are inoperable as a result of maintenance problems.

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agreements and orders, such as Harrinston v. DeVito, No. 74-C3290 (N.D. Ill. Oct. 19, 1978) (mental health care) and Jackson v. Sheriff of Cook Countv, No. 06-CV-493 (N.D. Ill. July 16, 2007) (STD testing). Despite the existence of these court orders, a myriad of unconstitutional practices remain at CCJ. The current court orders applicable to CCJ either do not include specific provisions governing the constitutional concerns raised below regarding protection from harm, inadequate medical and mental health care, fire safety, and sanitation, or have not resulted in lasting or effective corrective measures.
11. LEGAL STANDARDS
CRIPA authorizes the Attorney General to seek injunctive relief to enforce the constitutional rights of inmates subject to a pattern or practice of unconstitutional conditions in jails and prisons. 42 U.S.C. § 1997. In defining the scope of jail inmates1 Eighth and Fourteenth Amendment rights, the Supreme Court has held that corrections officials must take reasonable steps to guarantee inmatesf safety and provide "humane conditions" of confinement. Farmer v. Brennan, 511 U.S. 825, 832 (1994); Bell v. Wolfish, 441 U.S. 520 (1979) (holding pre-trial detainees protected by Fourteenth Amendment); Cavalieri v. Shepard, 321 F.3d 616, 620 (7th Cir. 2003). Providing "humane conditions" requires that a corrections system must "take reasonable measures to guarantee the safety of the inmates" and satisfy inmates' basic needs, such as their need for medical care, food, clothing, and shelter. Farmer at 832. The protection of pre-trial detaineesf rights under the due process clause of the Fourteenth Amendment is "at least as great as the Eighth Amendment protections available to a convicted prisoner." City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983).
When a jurisdiction takes a person into custody and holds him there against his will, the Constitution imposes upon it a corresponding duty to assume some responsibility for his safety and general well-being. County of Sacramento v. Lewis, 523 U.S. 833, 851 (1998) (citing DeShaney v. Winnebaqo Countv Dept. of Social Servs., 489 U.S. 189, 199-200 (1989)).
The duties imposed and rights conferred by the Eighth Amendment apply to the unreasonable risk of serious harm, even if such harm has not yet occurred:
We have great difficulty agreeing that prison authorities may not be deliberately indifferent to an inmate's current health problems but may ignore a condition of confinement that is sure or very likely to

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 7 of 99 PageID #:16
cause serious illness and needless suffering the next
week or month or year . . . . That the Eighth Amendment
protects against future harm to inmates is not a novel proposition. The Amendment, as we have said, requires that inmates be furnished with the basic human needs, one of which is reasonable safety.
Hellins v. McKinney, 509 U.S. 25, 33 (1993) (internal citations and quotations omitted); Woodward v. Correctional Medical Services of Illinois, Inc., 368 F.3d 917, 927 (7th Cir. 2004) (citing Farmer, 511 U.S. at 842).
The "Eighth Amendment prohibition against cruel and unusual punishment has been expanded under the Due Process Clause of the Fourteenth Amendment to impose upon both federal and state correctional officers and officials the obligation to take reasonable steps to protect inmates from violence at the hands of other inmates." Goka v. Bobbitt, 862 F.2d 646, 649-50 (7th Cir. 1988); see also Hudson v. Palmer, 468 U.S. 517, 526-27 (1984); Swofford v. Mandrell, 969 F.2d 547, 549 (7th Cir. 1992); Anderson v. Gutschenritter, 836 F.2d 346, 349 (7th Cir. 1988); Archie v. City of Racine, 847 F.2d 1211, 1222-23 (7th Cir. 1988) (en banc).
The Eighth Amendment forbids excessive physical force against prisoners. Hudson v. McMillian, 503 U.S. 1, 9 (1992). This is true even when the use of force does not result in
significant injury. Id. A jail or prison official who inflicts
force maliciously and sadistically to cause an inmate harm
violates the Eighth Amendment. Id.
Inmates also have the right to be free from retaliation for engaging in constitutionally protected conduct, such as complaining about conditions of confinement. Walker v. Thompson, 288 F.3d 1005 (7th Cir. 2002); DeWalt v. Carter, 224 F.3d 607, 618 (7th Cir. 2000) ('An act taken in retaliation for the exercise of a constitutionally protected right violates the
Constitution1').
While low staffing levels do not, by themselves, constitute due process violations, they provide support for a conclusion that the inmates are treated "recklessly or with deliberate indifference" to their safety. Swofford, 969 F.2d at 549. Similarly, although overcrowding is not a per se constitutional violation, overcrowding resulting in bunking multiple inmates in a single cell without adequate safety, space, sanitation, bedding, or opportunities for activities outside the cells can amount to unconstitutional conditions of confinement. French v. Owens, 777 F.2d 1250, 1252-53 (7th Cir. 1985) (holding that

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 8 of 99 PageID #:17
overcrowding was unconstitutional where it led to unsafe and unsanitary conditions); Wellman v. Faulkner, 715 F.2d 269 (7th Cir. 1983) (holding that prison was unconstitutionally
overcrowded); see also Nami v. Fauver, 82 F.3d 63, 67 (3d Cir .
1996) (holding that double-bunking coupled with extended in-cell periods despite safety hazards could constitute a constitutional
violation) .
A jailer's deliberate indifference to an inmate's serious medical needs violates the Eighth Amendment. Estelle v. Gamble, 429 U.S. 97, 102 (1976); Maqqert v. Hanks, 131 F.3d 670, 671 (7th Cir. 1997). "Deliberate indifference" involves both an objective and a subjective component. The objective component is met if the deprivation is "sufficiently serious." Farmer, 511 U.S. at 834. Prison officials may not refuse, unreasonably delay, or intentionally interfere with medical treatment for incarcerated individuals. Hudson v. McHuqh, 148 F.3d 859 (7th Cir. 1998) ("[Tlhis is the prototypical case of deliberate indifference, an inmate with a potentially serious problem repeatedly requesting medical aid, receiving none, and then suffering a serious injury." ) ; Zentmyer v. Kendall Countv, 220 F.3d 805 (7th Cir. 2000). "Deliberate indifference can be evidenced by 'repeated examples of negligent acts which disclose a pattern of conduct by the prison medical staff1 or it can be demonstrated by 'proving there are such systemic and gross deficiencies in staffing, facilities, equipment, or procedures that the inmate population is effectively denied access to adequate medical care.'" Wellman, 715 F.2d at 271 (citing Ramos v. Lamm, 639 F.2d 559, 575
(10th Cir. 1980), cert. denied, 450 U.S. 1041 (1981)) . Jail
officials also may not provide an easier but less efficacious course of treatment nor may they offer only cursory medical care when the need for more serious treatment is obvious. See Estelle, 429 U.S. at 104-05. Failure to provide medication can violate the duty to provide adequate medical care to address serious medical needs. See, e.q., Zentmyer, 200 F.3d at 811.
The County's obligation to provide adequate medical care includes a duty to provide adequate mental health care. Farmer, 511 U.S. at 832; Sanville v. McCauqhtry, 266 F.3d 724, 734 (7th Cir. 2001) (noting that a mentally ill inmate's condition was "objectively, sufficiently serious" such that incarcerating him under conditions that posed a substantial risk that he would commit suicide subjected him to cruel and unusual punishment). In addressing the constitutionally minimal standards for mental health care in a jail or prison, the Seventh Circuit notes: "When a claim is based upon the failure to prevent harm, in order to satisfy the first element the plaintiff must show that the inmate was 'incarcerated under conditions posing a substantial

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risk of serious harm.'" Id. (citing Farmer, 511 U.S. at 832);
see also Estate of Novack v. County of Wood, 226 F.3d 525, 529 (7th Cir. 2000); Estate of Cole v. Fromm, 94 F.3d 254, 261 (7th Cir. 1996). Where a jail's "actual practice" towards treatment of mentally ill inmates in general is clearly inadequate, the facility may be held to be 'on notice" at the time of an inmate's incarceration that there is a substantial risk of deprivation of necessary care. Woodward, 368 F.3d at 927 (practice of inadequate employee training, incomplete intake screening, and inadequate suicide watch constituted deliberate indifference).

The risk of suicide is an "objectively serious harm" from which inmates have a right to protection, under the deliberate indifference standard. Matos v. O~Sullivan,335 F.3d 553, 557 (7th Cir. 2003). Inadequate suicide prevention may constitute deliberate ,indifference. Hall v. Rvan, 957 F.2d 402, 406 (7th Cir. 1992) (noting that prisoners have a constitutional right "to be protected from self-destructive tendencies," including suicide); Woodward, 368 F.3d at 929 (fact that no previous suicides occurred in jail did not negate possibility of a practice of deliberate indifference toward suicidal detainees); Cavalieri, 321 F.3d at 620 (holding that the right to be free from deliberate indifference to suicide was clearly established).

Inmates are constitutionally entitled to environmental

conditions that do not pose serious risks to health and safety,

including deficient sanitation, inadequate fire safety,

inadequate ventilation, and pest infestation. Vinnins-El v.

Lonq, 482 F.3d 923, 924-25 (7th Cir. 2007) (holding that

deliberate indifference could be established by inference from

conditions, including floor covered with water, broken toilet,

blood and feces smeared along wall, no mattress to sleep on);

. . Gillis v. Litscher, 468 F.3d 488, 568 (7th Cir. 2006) ('[A] state

must provide

. reasonably adequate ventilation, sanitation,

bedding, hygienic materials, and utilities (i-e.,hot and cold

water, light, heat, plumbing)."); Board v. Farnham, 394 F.3d 469

(7th Cir. 2005) (requiring adequate ventilation); Isbv v. Clark,

100 F.3d 502, 506 (7th Cir. 1996) ("Sanitation, we assume,

includes things like odors and general cleanliness around the

cell.") (emphasis in original); French, 777 F.2d at 1257 (holding

that fire safety is a "legitimate" concern under the Eighth

Amendment); Antonelli v. Sheahan, 81 F.3d 1422, 1432 (7th Cir.
1995) (requiring adequate pest control) .

In addition, detainees have a right to be free of bodily restraints, such as shackles or a restraint chair, unless the facility demonstrates a legitimate penological or medical reason for the restraint. Murphy v. Walker, 51 F.3d 714, 718 (7th Cir.

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1995). Where restraints are used, the inmate should be properly monitored and the length of restraint-time should be limited to ensure the inmate's safety. French, 777 F.2d at 1253-54. Restraints imposed by correctional officers that are medically unjustifiable and have no adequate security rationale infringe on an inmate's due process rights. Wells v. Franzen, 777 F.2d 1258, 1263 (7th Cir. 1985) (restraint of a suicidal inmate).
FINDINGS
We find that CCJ fails to adequately protect inmates from harm and serious risk of harm from staff and other inmates; fails to provide inmates with adequate medical and mental health care; fails to provide adequate suicide prevention; fails to provide adequate fire safety precautions; and fails to provide safe and sanitary environmental conditions.
A. INADEQUATE PROTECTION FROM HARM
Corrections officials must take reasonable steps to guarantee inmates' safety and provide "humane conditions" of confinement. Farmer, 511 U.S.. at 832. Providing humane conditions requires that a corrections system must satisfy inmates' basic needs, such as their need for safety. Additionally, jail officials have a duty to take reasonable steps to protect inmates from physical abuse.
To ensure reasonably safe conditions, officials must take measures to prevent the use of unnecessary and inappropriate force by staff. Officials must also take reasonable steps to protect inmates from violence at the hands of other inmates. In addition, officials must provide adequate systems to investigate . incidents of harm, including staff misconduct and alleged physical abuse of inmates. Finally, a jail'hasan obligation to protect vulnerable inmates from harm, such as those who are at risk of suicide or at risk from other inmates. For the reasons set forth below, CCJ fails to meet constitutional standards in all of these regards.
1. Inappropriate and Excessive Use of Force
Although the violence present in a correctional setting necessarily permits the appropriate use of force, the Constitution forbids exce'ssive physical force against inmates. A determination of whether force is used appropriately requires an evaluation of the need for the use of force, the relationship between that need and the amount of force used, the seriousness of the threat reasonably believed to exist, and efforts made to temper the severity of a forceful response. Hudson v. McMillian,

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 11 of 99 PageID #:20
503 U . S . 1, 7 (1992). Generally accepted correctional practices provide that appropriate uses of force in a given circumstance should include a continuum of interventions, and that the amount of force used should not be disproportionate to the threat posed by the inmate. Absent exigent circumstances, lesser forms of intervention, such as issuing disciplinary infractions or passive escorts, should be used or considered prior to more serious and forceful interventions.
We found that inmates at CCJ are regularly subjected to inappropriate and excessive uses of physical force. CCJ officers too often respond to inmates1 verbal insults or failure to follow instructions by physically striking inmates, most often with the active assistance of other officers, .even when the inmate presents no threat to anyone's safety or the security of the facility. Moreover, even in cases in which the initial use of force is reasonable, officers sometimes continue to engage in physical force after the inmate has been brought under control or is effectively restrained.
A top security administrator frankly acknowledged to us the existence of 'a culture of abusing inmates" when he came to CCJ in October 2006. While senior management has taken steps to reduce the use of force, such as requiring Use of Force Reports and by subjecting these documents to greater scrutiny, the excessive and inappropriate use of force has not been brought under control. We believe that, despite management's efforts, a culture still exists at CCJ in which the excessive and inappropriate use of physical force is too often tolerated.
Our investigation included an intensive examination of documents provided by CCJ concerning the incidents listed below and a host of others occurring between January 2006 and July 2007. We also conducted a great many staff and inmate interviews. In some cases, our findings of inappropriate or excessive uses of force are in accord with CCJrs own conclusions.
a. Use of Force in Response to Verbal Altercations
The use of force, while sometimes necessary in a corrections setting, must be appropriate to the given circumstances and proportionate to the threat posed. A verbal taunt from an inmate to an officer is a rule violation and may appropriately result in disciplinary action, but it should not require a physical response. As the examples below demonstrate, verbal altercations with inmates too often provoke physical responses from CCJ officers :

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In July 2007, following his hour of exercise, Alberto P . ~refused to return to his cell and a female officer locked the cell doors while Alberto remained outside. He called the officer a 'b----." When Alberto came out with his property to be moved to disciplinary segregation for insulting the officer, he was beaten by a number of officers. One officer later told Alberto that he had tried to stop the beating, but he just 'didn't have enough juice" (apparently explaining his inability to control the other officers). CCJ records confirm that Alberto was transferred to segregation and taken to Cermak for his injuries.
2. In June 2007, Dennis L. returned to his cellblock after a psychological evaluation. An officer refused to give Dennis a dinner tray. Dennis got into a verbal altercation with the officer and threw a cup of liquid at him. A number of officers attacked Dennis in his cell. Emergency Room records indicate that Dennis suffered blunt trauma to his head and body, three teeth knocked loose, and a laceration to his lower lip from this incident.
3. In April 2007, Billy D. wanted to exit his cell and was accused of pushing his way out. He had a "heated" verbal altercation with the officer. One officer struck Billy in the face and other officers joined in. Medical records show that Billy required internal and external stitches to close a one-inch laceration that punctured his lip.
4. In September 2006, an officer was handing out extra lunches to inmates. Malcolm W. asked for one, but was refused. Malcolm and the officer exchanged verbal insults. A mental health staff member and another inmate witnessed the officer slap Malcolm's face and drag him from the dorm. CCJ1s Internal Affairs Division ("IAD") sustained allegations of abuse, and recommended that the officer be suspended for 29 days. The officer was "dedeputized" and prohibited from carrying a firearm or effecting arrests.
6 To protect privacy, we have used pseudonyms to identify inmates and officers listed in this letter. Upon request, we will provide the County with a schedule that cross-references the pseudonyms with the proper names, where appropriate.

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5. In March 2006, Danny P., who according to CCJ records

was a slight man of 5'1" and 110 pounds, was on his way

to the law library. He got into a shouting match with

the female officer escorting him, which resulted in him

being taken back to his housing unit. Near the secure

staff station, the officer lunged at Danny and began to

slap him. Two other officers grabbed his arms and

pushed him into a dayroom. As he was being handcuffed,

I

several other officers continued to punch and kick him.

He was hit in the mouth after being handcuffed. CCJ

records show that a sergeant found Danny standing

I

outside the security office handcuffed and bleeding

I

about the face. The female officer was disciplined for

I

failing to report the incident in a timely manner and

I

also for failing to obtain medical treatment for Danny.

Danny filed a lawsuit against CCJ regarding this incident, and the parties agreed to settle the case in March 2008.

b. Use of Force for Failure to Follow Instructions

It is inappropriate and excessive to use force for rule violations which do not present a threat to safety or security. At CCJ, inmates1 failure to follow orders too often lead to physical abuse, even where no security risk is present:

1. In June 2007, there was a fight on Thomas K.'s unit, in which he did not participate. A group of officers came to the unit, strip-searched the inmates, and sent them back to their cells. As Thomas started to go up the stairs to his top tier cell, his hands were on his neck holding his shirt, instead of on top of his head, as he had been directed. An officer grabbed Thomas by the neck, which choked him, and Thomas reacted by grabbing the officer's arm. The officer immediately swung and hit Thomas in the eye with a walkie-talkie, causing a wound that required five stitahes to close. Cermak medical records confirm Thomas's injuries and that he was hit with an "unknown object." The officer continued hitting Thomas after the first blow, although Thomas offered no resistance. We observed Thomas's injuries during our on-site visit.

2. In February 2007, Matthew S. was ordered to leave the barber shop for standing up before his turn. When he tried to explain why he stood up, an officer grabbed him by the collar and told him to leave the barber shop. Matthew argued with the officer. Outside the

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barber shop, officers shoved his head into the concrete after he had been handcuffed. CCJ records confirmed that Matthew needed.stitchesto his face and a tetanus shot following this incident, but he refused treatment.
3. In April 2006, Terrence M. was being processed in his division when an officer noticed that Terrence had an unauthorized shirt. The officer asked for the shirt, but Terrence refused to give it to him. After Terrence was restrained, the officers punched and kicked him. As a result of the beatin-q, Terrence suffered a broken jaw that required surgery at an outside hospital. CCJ found abuse by one officer, and the officer was terminated.
4. In April 2006, Darnel1 J. refused to go to recreation when he was told he could not first use the bathroom. Several officers shoved Darnel1 into the hallway where they beat and kicked him. A sergeant watched and then joined in the beating. Two other inmates in the hallway were also beaten. Darnel1 was hospitalized for neck injuries. CCJ found abuse by the sergeant and seven officers and also that the sergeant and several officers had filed false reports. IAD recommended termination for the sergeant and three officers.
In March 2006, John S. was being strip-searched prior to going to recreation. He was tapping on the wall. An officer ordered him to stop and hit him on top of the head. John continued to tap. After John was searched, the officer said: "You're f------guilty" and slammed him on top of a cart and against the wall. John was pulled into the hallway where other officers started to beat him. He was hit in the face, dragged by his hair, choked, and beaten. Photographs of John in the CCJ files show injuries to his face and body. IAD found that the officers used excessive force and recommended that two officers be terminated.
6. In March 2006, Jacob D. objected to a tier change and insisted on speaking with an officer. Three officers extracted him from his cell. He was handcuffed behind his back and, while they were taking him to the segregation.unit, the officers pushed his head into the wall. He was hit in the face, thrown down stairs, kicked, and punched repeatedly. Photographs of Jacob from the following day show that his face was badly bruised and his eye was swollen shut. IAD found that

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three officers used excessive force and recommended that they be suspended for 2 9 days.
7. In January 2006, Byron S. was cleaning the dayroom with other inmate workers when a group of officers accused Byron and another inmate of planting contraband in the visiting area, and took both inmates into the hallway. Byron was beaten by multiple officers. After he was handcuffed and lying on the floor, Byron received a blow that broke his jaw. Medical records confirm that his jaw was fractured. Byron's jaw was wired shut at an outside hospital, which required him to eat with a straw. Three months later, Byron required additional surgery and his jaw was wired shut for a second time. Byron filed a lawsuit against CCJ regarding this incident, and the parties agreed to settle the case in September 2007.
8. In January 2006, Michael A. was resisting going to disciplinary segregation because he believed he had already served his time for the infraction in question. He asked to talk to a sergeant, who said that nothing could be done. When he continued to resist, stating that he wanted to talk to a captain, a correctional officer said: "No," and struck him in the face. Other officers were called and joined in beating him. He was sent by ambulance to an outside hospital. Medical records show he suffered a fractured nose and two black eyes.
c. Use of Force as Punishment or Retribution
We found that inappropriate and excessive use of force also occurs when officers are angry and upset about inmate violence against staff. Physical force is also sometimes inappropriately used at CCJ even after an active dispute between an inmate and officer has ended, apparently to punish the inmate. Retaliatory force even occurs when officers are dealing with mentally ill inmates with limited impulse control, although the inmates do not present a threat to themselves or other^.^ The use of.force is
7 According to a division superintendent, a number of officers assigned to the tiers for inmates with mental illness have not received training on working with the mentally ill. The excessive use of force with mentally ill inmates is likely attributable to lack of, or ineffective, officer training.

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never appropriate as retribution for previous bad acts and is inappropriate when an inmate is not a present threat:
1. In July 2007, Robert T., who suffers from mental illness, exposed himself to a female officer. In response, he was taken to a clothing room where a group of officers handcuffed him and then proceeded to hit and kick him after he was restrained. CCJ records confirm that Robert was sent to an outside hospital with severe head trauma.
2. InJune 2007, Russell G.'s cellmate openedthe cell door and Russell got out of his cell. In response, an officer locked all the inmates in their cells. After Russell was back in his cell, officers sent his cellmate downstairs and entered Russell's cell. The officers handcuffed Russell, then stomped on his back and hit him. His eye became swollen and his teeth were chipped. Before taking him to the dispensary, the officers threatened to beat Russell again and charge him with battery unless he told medical staff that he had hurt himself falling off his bunk. Russell was sent from the dispensary to Cermak Hospital for medical treatment.
3. In August 2006, an inmate stabbed an officer. Because Martin S. had argued with the officer earlier in the day, officers erroneously believed he had committed the ~ t a b b i n g .A~s a result, officers responded to an "all available" call and began to'beat Martin in the mistaken belief that he was the inmate who had assaulted the officer. Besides being punched and stomped, he was also hit with a radio and kicked in the groin.
4. Inmate Andrew B. was also housed in the unit where the August 2006 attack on the officer occurred. Andrew had nothing.todo with the attack. A large number of officers came onto the unit and proceeded to beat the inmates indiscriminately. Andrew was ordered to lie down and, while he promptly obeyed, he was stomped and kicked by the officers.
8 CCJ records confirm that another inmate was charged with the crime.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 17 of 99 PageID #:26
5. In April 2006, Damien H. pushed out of his cell. An officer escorted him back to his cell. At the door of his cell, Damien turned and hit the officer, for which he was charged with aggravated battery. All available officers were called and, while restraining Damien, several officers punched, kicked, and stomped him. IAD found that three officers had used excessive force and recommended 29-day suspensions for all of them.
6. In January 2006, an officer wanted Jerry M. to return to his cell, which Jerry resisted, and the officer rolled the door over Jerry's foot. Jerry called the officer a 'b----." The officer then beat Jerry with' handcuffs wrapped around his hand like brass knuckles. A CCJ internal investigation of this incident found that excessive force had been used and recommended that the officer be terminated. The Sheriff's Merit Board, which hears CCJ termination cases, ruled against CCJ and reinstated the officer to duty.
d. Use of Force at Intake
The pattern of inappropriate and excessive use of force is distributed throughout the CCJ divisions, and not confined to the areas where the use of force is most likely to occur in a correctional setting: the maximum security units and intake area. However, an especially high number of abuse of force allegations do emerge from CCJrs RCDC intake unit.
There is unanimity of opinion among those familiar with CCJ, including administrators and staff, the County, the Sheriff's Office, and the court monitors, that conditions in RCDC are unacceptable and must be changed. As discussed in more detail below, the RCDC is chronically overcrowded, cramped, chaotic, and insufficiently staffed. The impact of these conditions on the use of force is considerable. In the RCDC, inmates who request attention for various needs run the risk of becoming victims of physical abuse. Inmates are especially vulnerable to abuse when they are taken in large groups to be strip searched in an isolated area out of the view of non-security intake staff. Many inmates report that those who are old, mentally ill, or do not understand English, are struck by officers for undressing or dressing too slowly. Finally, inmates may also be targeted for physical abuse because of the charges for which they were arrested.
1. In September 2006, Pedro S. was arrested on a sex chaTge brought by his niece. While in the intake area,

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 18 of 99 PageID #:27
three officers who had read his charge began taunting him, yelling threats in Spanish, and asking if he knew what was about to happen to him. The officers struck him many times and called him a 'f------ Mexican." The other inmates were ordered to turn and face the wall 'or else." Because the officers threatened to kill Pedro if he said anything about the incident, he did not seek medical attention. Pedro was released four days later and immediately saw a doctor and reported the incident to the Chicago Police Department. The Police Department contacted CCJ. Medical records confirm that Pedro's injuries included a broken rib and damage to his jaw and knee.
2. In July 2006, Lonnie L., 59-years-old,was leaving the medical area of intake and heading to the bullpen. When he turned around to get more medication, an officer told him not to return to the medical area. Lonnie did not obey the order. The officer came into the medical area and hit Lonnie on the mouth. When Lonnie fell to the ground, the officer kicked him and again struck him in the mouth, knocking out a tooth. The officer dragged Lonnie by the pants out of the medical area. During Lonnie's intake strip search, the same officer hit him in the back with a cane. Three inmates testified that they witnessed the incident. Medical records indicated injury to Lonnie's ribs and lung. CCJ found abuse and recommended that the officer be terminated.
3 . While being processed into CCJ in May 2006, Antonio R. was wandering around the intake area asking for his methadone. An officer told him to return to his holding pen. Antonio apparently did not obey quickly enough, as the original officer and others proceeded to beat him, first in the main open area and then in an adjoining tunnel. They hit Antonio with a radio, knocked out his dentures and smashed them under a boot. As a result of this incident, Antonio suffered multiple fractures and a collapsed lung. After being returned from one outside hospital, he was sent to another in acute respiratory distress. He was transferred to a Level 1 trauma center, where he needed to be placed on a ventilator. Medical records confirm Antonio's severe injuries.
4. In February 2006, while being processed into the CCJ for driving on a suspended license, James W. would not

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(and could not) remove jewelry embedded in a piercing because it was permanently soldered. The officer conducting the strip search attempted to strike James, who blocked the blow. The officer then called over other officers, who hit James in the face multiple times. One officer hit him repeatedly with a handcuff wrapped around his hand. James later stated that the officers had used his head as a "bongo drum." Medical records confirm that James was diagnosed with a perforated ear drum and blood in his right ear at Cermak Hospital the next day. Additional records show that the incident resulted in diminished hearing in one of James's ears. James filed a lawsuit against CCJ concerning this incident and the parties agreed to settle the case in March 2008.

e. Inadequate Oversight of Use of Force

'Effective measures to prevent excessive and inappropriate uses of force start with the adequate reporting of information to permit the identification of potential problem cases and effective internal investigations. We find that CCJ fails to elicit adequate information about use of force incidents, making management review ineffective. We also find that, in most cases, internal affairs investigations of use of force are undertaken only when a lawsuit is filed, rather than when a serious incident occurs.

I

i. Management Review

In order for CCJ to provide adequate oversight of officersr use of force, management must have adequate information to review incidents and reach a conclusion as to the propriety of a use of force. While all officers involved in a use of force incident fill out a Use of Force Report, in most cases these reports provide very little information because they are written in generalities. For example, numerous Use of Force reports fail to describe, in factual terms, the type and amount of force that officers used. Many Use of Force Reports merely describe the force used with phrases such as, 'used the least amount of force necessary to gain control of the inmate" or "faced inmate to the floor." Although most shift commanders review Use of Force and Incident Reports to ensure that reports are completed, some commanders reported that they do not review the reports for substantive content. Although copies of Incident Reports are forwarded to CCJrs Executive Director, Assistant Executive Directors, Superintendents, and the official file, it is unclear

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if the administration routinely conducts any additional review of these reports.
Moreover, while in most cases there are both Incident Reports and Use of Force Reports, the reports generally do not indicate the nature or extent of an inmate's injuries, arguably the most telling indication that there may have been an inappropriate use of force. The reports usually conclude with an inmate being taken for "medical attention," but with no indication of why medical attention was required. The reports also fail to capture the time the inmate received medical attention, which makes it difficult to assess whether medical attention was promptly provided. In the May 2006 case of Jacob D., there is no indication of any injury in the CCJ reports, but when Jacob was transferred the next.day to the Illinois Department of Corrections ("IDOC"), his facial bruising and swelling was so severe that the IDOC contacted CCJ immediately to report the physical condition of the incoming prisoner. In the case of John S., there is also no indication of injury in the CCJ reports about a March 2006 incident. The reports simply state that John was taken for medical attention and released from the dispensary, with no mention of any injuries. In fact, as photos taken later show, John suffered two black eyes and a swollen lip, among other injuries. In both of these cases, CCJ eventually found excessive use of force by the officers, but the reports themselves were devoid of helpful inf~rmation.~
Because the information contained in Use of Force and Incident Reports is insufficient for management to determine whether the incident raises suspicions concerning use of force, review by management, when it occurs, usually does not result in identifying cases for investigation. There can be no effective oversight if necessary information is not put forth when the incident happens. For example, a report indicating that an inmate sustained a black eye after an inmate-officer altercation should raise concern, but management will never know about the black eye under the current system.
In addition to the lack of information contained in CCJ reports, we discovered that the Incident Reports did not contain a tracking number or source of issuance until a July 2007 initiative by the Executive Director. This initiative is consistent with generally accepted correctional practice. Previously, it was extremely cumbersome to track any one incident
9 In both of these cases, investigations were initiated as a result of external complaints.

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(for use of force and other serious incidents) and, in all likelihood, impossible to ascertain if all incidents were being reported and processed. Incident tracking numbers are now to be issued by External Operations staff. Serious incidents and uses of force should also be tracked by each division with a uniform logging system for recording serious incidents at all levels of CCJ.
Finally, CCJ has no tracking or early warning system to identify those officers who are the most frequent users of physical force and those whose actions have elicited the most complaints of excessive force, grievances, or injuries. An appropriate early warning system is an accountability tool that allows for early intervention by alerting a facility to a need for retraining, problematic policies, supervision lapses, or possible bad actors. In 2004, CCJ hired an external consulting firm to review its policies and procedures regarding the use of force after a special grand jury concluded that a 1999 incident, in which correctional officers beat and terrorized 49 inmates at CCJ, constituted "gross, if not criminal, misconduct." The consulting report recommended that CCJ institute an early warning system 'as soon as possible." The 2004 recommendation was never implemented.
ii. Investigations
To ensure reasonably safe conditions for inmates, correctional facilities must develop and maintain adequate systems to investigate staff misconduct, including alleged physical abuse by staff. Beyond management review, the avenue
for oversight at CCJ is the Internal Affairs Division ("IADN).
Generally accepted correctional practices require clear and comprehensive policies and practices governing the investigation of staff use of force and misconduct. Adequate policies and practices include, at a minimum, screening of all Use of Force and Incident Reports, specific criteria for initiating investigations based upon the report screening, specific criteria for initiating investigations based upon allegations from any source, timelines for the completion of internal investigations, and an organized structure and format for recording and maintaining information in the investigatory file. The investigation must also be and appear to be unbiased. CCJ1s investigatory practice fails on multiple levels.
To be effective, investigations must be undertaken promptly. A jail, by its nature, has a tremendously high turnover of inmates. An inmate whose incident is being investigated may well have left CCJ if the investigation does not occur soon after the

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incident, and the same is true for inmate witnesses. Because CCJ does not initiate many use of force investigations, most use of force investigations are not opened until long after an incident has taken place. Instead, investigations are undertaken because the inmate has filed a lawsuit, which can be up to two years after an incident occurs. For example, the investigation of Michael A.'s January 2 0 0 6 beating did not begin until 1 6 months after the incident, despite the fact that Michael was treated at an outside hospital, suffered a fractured nose, and had, according to the medical records, 'raccoon eyes." The investigation of the incident in which Byron S. suffered a broken jaw did not start until Byron filed suit seven months later, even though Byron's visible injuries required him to eat through a straw with his jaw wired shut. Because of the delay, inmate witnesses to the occurrence will likely have left CCJ by the time an investigation begins. IAD1s only attempt to reach an inmate witness who has left CCJ is a form letter to a last known address, which rarely elicits any response. We found that many investigations are simply undertaken far too late to be effective.
Perhaps even more troubling is the fact that investigations are reactive and suffer from the appearance of bias. The vast majority of IAD files we reviewed stated that the investigation of use of force was opened at the request of CCJ1s attorney in response to an inmate lawsuit CCJ is defending in court. It is almost impossible for IAD to appear fair and unbiased when the investigation is undertaken only because CCJ is defending an inmate lawsuit. All uses of force should be appropriately reviewed through the chain of command. Whenever Incident Reports, Use of Force Reports or other information raise the possibility that excessive force was used, such incidents should be thoroughly investigated by IAD. In particular, incidents involving suspicious inmate injuries, such as black eyes or blunt head trauma, and incidents requiring medical care at an outside hospital should be investigated by IAD. An appropriate evaluation of incidents for investigation will require more detailed Use of Force and Incident Reports and a more thorough management review than CCJfs current practice.
IAD also reported a backlog in resolving use of force cases and incidents involving inmate-on-inmate assaults because it is difficult to obtain medical releases from Cermak, CCJ1s on-site health care provider, in a timely manner.1° Obtaining medical
10 IAD is under the Sheriff's Office while Cermak is part of the Cook County Bureau of Health.

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records from Cermak can take anywhere from six to 12 months, which prevents IAD from bringing prompt closure to an investigation. This type of delay is totally unacceptable, and is devastating for any investigation.
We also found that there are attempts by officers or other staff to conceal the inappropriate or excessive use of force. CCJ officials found that the officer involved in the January 2006 beating of Jerry M. had attempted to persuade a sergeant on the tier to change his story as to what had happened. In another case, Russell G. reported that the officer who caused his injuries in June 2007 threatened him with worse treatment unless he told the medical staff that he had hurt himself by falling out of his bunk. We found two accounts of senior division staff attempting to dissuade inmates from complaining about the use of force, in one case by the offer of a favor and in the other by the threat of criminal charges. CCJrs administration and IAD must take action to ensure that inmates are not intimidated into concealing excessive use of force and that information received is accurate and credible.
Finally, we also found flawed investigatory techniques at CCJ. For example, investigators often do not give sufficient attention to the inmate injuries that are known. When investigators question officers accused of using excessive force, the officers are generally not even questioned as to how an inmate's particular injury might have occurred. For example, IAD opened an investigation of the March 2006 case of Antonio R. after a doctor at an outside hospital reported that Antonio was in serious condition with "blunt trauma all over his body." Although the investigator was aware of Antonio's injuries at the time he questioned both of the officers involved, he never asked the officers about the nature of Antonio's injuries or how they occurred. While there may sometimes be tactical reasons to avoid discussing inmate injuries when an officer is first questioned, the investigation is incomplete if the officers are never asked to address the inmate's resulting injuries.
We found other examples of investigatory techniques that are unlikely to result in complete or credible information. For example, on March 9, 2006, an investigator interviewed inmate Gabriel M. about a use of force incident involving another inmate in his tier. The investigator then attempted to interview Gabriel's' cellmate about the same incident but, since the cellmate could not speak English, the investigator utilized Gabriel as the Spanish interpreter to provide his cellmate's statement. Relying on one inmate to translate for another inmate in an investigation involving both of them is a poor

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investigatory technique that calls into question the credibility of the information gathered by CCJ investigators.ll
iii. Videocameras and Overhead Cameras
When properly utilized, cameras in a correctional setting can augment inmate safety and security and provide essential information for investigations. Certainly video surveillance should never be used to substitute for direct officer supervision of inmates, but it often is helpful to supplement supervision and for incident reconstruction. CCJ has limited and antiquated live feed overhead cameras in some divisions, but the cameras do not have the critical capability to record and replay, and most do not capture activities outside of the housing unit dayrooms. Moreover, while there are two small monitors in the RCDC intake area, we discovered that the officers in the Security Office were unaware that the monitors could view various parts of the intake area. The cameras, installed to monitor activity in a part of CCJ that had experienced among the highest number of allegations of excessive and inappropriate uses of force, were not being used.
Procedures at CCJ require that a handheld videocamera be brought to the scene of any use of force and that the use of force be recorded. While this policy is he-lpful for review of cell extractions and other planned uses of force, it is not surprising that the use of handheld videocameras has not been an effective means of oversight for unplanned uses of force. None of the numerous videotapes we reviewed captured an unplanned use of force in progress. Improvements and additions to CCJ1s video surveillance system, including the ability to record for retrieval following an incident, would be a much more effective oversight mechanism.
2. Deficient Inmate Safety and Supervision
CCJ does not provide adequate inmate supervision, which exposes inmates and staff to unsafe conditions. Lack of adequate
l1 Title VI of the Civil Rights Acts requires that recipients of federal funds take reasonable steps to provide meaningful access to limited English proficient communities. Given Cook County's growing Hispanic population, CCJ should ensure that some investigators and correctional officers are familiar with rudimentary Spanish. In addition, CCJ staff would benefit from receiving diversity training. See Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d & sea.

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security staff, insufficient direct supervision in the majority of the housing units, a dilapidated physical plant, inadequate policies and procedures, and an overcrowded environment combine to result in an unsecure facility that is dangerous for everyone on the premises. On April 9, 2007, the John Howard Association found that the rates of injuries to CCJ inmates and staff have increased significantly in the past decade, despite a substantial decrease in inmate population.12 In 2006, inmate injuries occurred at the highest rate since the John Howard Association began gathering data, and staff injuries reached the third highest rate since 1991.13 Our review of CCJ documents revealed that between January 1, 2007 and June 19, 2007, IAD opened approximately 254 cases involving inmate assault and/or battery and five cases of sexual assault. In 2006, IAD opened approximately 357 cases involving inmate assault, battery, or sexual assault.
Insufficient inmate supervision has been a serious problem at CCJ for decades. Inmate supervision is seriously compromised by chronic overcrowding and under-staffing. The federal district court monitoring the Duran Consent Decree has repeatedly cited CCJ for failing to provide adequate security staff to ensure safe and secure conditions at the facility.14 In September 2006, then-Sheriff Michael Sheahan admitted that the Jail is "severely under~taffed."~T~he John Howard Association's April 9, 2007 report found that CCJ would require an additional 189 new correctional officers and suitable replacements for the 130 to
12 Court Monitoring Report, Duran v. Dart, No. 74-C-2949, at 115-16 (N.D. Ill. Apr. 9, 2007) ("2007 Court Monitoring Report"). Monthly averages for'staff injuries have risen from 6.6 in 1996 to 28.3 staff injuries per month in 2006.
13 Id.at .116. Monthly averages for inmate injuries
increased-from 14.7 injuries per 1000 inmates in 1996 to 27.8 injuries per 1000 inmates1 in 2006.
14 Leonard N. Fleming, "Federal Judge Warns County to Fix Overcrowding at the Jail," Chicaso Sun Times, Dec. 1, 2007; Jonathan Lipman, "Judge Blasts Staffing at Jail," Daily Southtown, Dec. 29, 2005.
Joint Status Report, Duran v. Dart, No. 74-C-2949, at 8
(N.D. Ill. Sept. 29, 2006) .

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152 correctional officers on inactive status16 to comply with the Duran Consent Decree and "good correctional practices."17 CCJ's Post Analysis Reports and Divisional Staffing Reports for April through June 2007 revealed that at least 172 correctional officer positions at CCJ were vacant or inactive. Although the External Operations Unit, which is responsible for the security of the CCJ perimeters, the Emergency Response Team, the Canine Unit, and the transportation of 800 to 1500 inmates to and from court daily, has an authorized security staffing complement of 420 positions, on May 1, 2007, the actual External Operations manpower availability comprised 352 positions. Our expert consultant found that the level of correctional staff available to supervise housing units at CCJ is woefully inadequate.
The lack of adequate staff is magnified by the fact that CCJ is chronically overcrowded. In fact, every day from June 2006 through April 2007, numerous inmates were required to sleep on the floor of two-person cells that housed three inmates.18 Divisional reports for the period of ~ e b G u a r2~6, 2007 through June 17, 2007 reflect that an average of 485 inmates were forced to sleep on the floor each night. During our site visit on July 23, 2007, Division VI held 1268 inmates in space with a rated capacity of 992 inmates.lg Dormitory Four in Division I1 is operating at twice its design ~apacity.~'However, we did not observe any increase in security staffing levels or enhanced supervision practices within the overcrowded divisions.
Overcrowding has an impact on security at CCJ. For example, the week of March 19, 2007, CCJ had more inmates sleeping on the floor (591) than any other week in the four-month period of March through June 2007. During that week, CCJ also had the most fights (35), the most uses of force (27), and found the third most "shanks" (homemade knives) (34) and second most weapons
16 Correctional officers on 'inactive status" include persons on disability, suspension, leave of absence, military leave, or leave for a duty injury.
l7 2007 Court Monitoring Report at 84.
l9 The actual capacity of Division VI was much lower than 992 on July 23,.2007, due to numerous cell closures because of maintenance problems, which further exacerbated the overcrowding.
20 2007 Court Monitoring Report at 15.

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(12), of any other week during the same period." On November 30, 2007, Judge Virginia Kendall for the United States District Court for the Northern District of Illinois apparently chastised the County and Sheriff's Office for failing to ease overcrowding at CCJ, stating: "This is no longer a budget problem. It is a constitutional violation."22 Despite the fact that CCJ has been subject to the Duran Consent Decree for 25 years, the County and the Sheriff's Office have been unable to solve the problems of overcrowding and inadequate supervision at CCJ.

CCJ has taken some unusual steps to try to deal with the

problems of overcrowding and inadequate staffing. The practice

of cross watching, discussed below, is an unacceptable and

dangerous approach. A recently instituted policy of extended

lockdowns is similarly unacceptable. In the spring of 2007, CCJ

implemented extended lockdown periods for all general population

inmates. Under this system, only half of the inmates in each

housing tier were allowed out of their cells during each shift.

Generally, this meant that half of the inmates were allowed out

of their cells for a period in the morning, half of the inmates

were allowed out of their cells for a period in the afternoon and

evening, and all of the inmates were locked in their cells during

the night. Because the groups of inmates rotated on a shift by

shift basis, the result was that every other day each group of

inmates spent a continuous 26-hour period locked inside the

cells. This practice was applied indiscriminately to all general

population inmates, except those housed on the medical units. As

discussed in further detail below, in addition to constituting an

unjust restriction on pre-trial detainees, the extended lockdown

practice interfered with medical and mental health care,

programs, and .thegrievance system. Moreover, deficient

maintenance in many cells (no lighting, plumbing failures, etc.)

-

-

resulted in inhumane conditions for an extended lockdown.

~

Therefore, as a result of CCJfs inadequate supervision, inmates

are subjected to unjustified, prolonged periods of in-cell

confinement. Following our July 2007 visit, the Sheriff's Office

informed us that CCJ had revised the lockdown policy to decrease

the length of the in-cell periods. This would be an improvement

Weekly averages for March through June 2007 were: 23.5 fights, 17 uses of force, 23.5 shanks, and 6.6 weapons.
22 Staff Writer, 'Judge Orders Cook County to Fix Jail
Overcrowding," PR Newswire Europe, Nov. 30. 2007; Leonard N. Fleming, "Federal Judge Warns County to Fix Overcrowding at the Jail," Chicaqo Sun Times, Dec. 1, 2007; Notification of Docket Entry, Duran v. Dart, No. 74-C-2949 (N.D. Ill. Nov. 30, 2007).

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 28 of 99 PageID #:37
and a welcome change, and we look forward to assessing the new lockdown system.23
As discussed below, the result of CCJJs inadequate inmate supervision is that inmates and staff are exposed to unsafe conditions, an increased risk of violence and an abundance of dangerous and illegal contraband.
a. Assaults on Inmates and Staff
The severity and frequency of inmate-on-inmate assaults demonstrate that CCJ is not providing for the safety and well-being of the inmates. In a period of less than two months in the spring of 2006, inmates reportedly engaged in at least seven separate knife fights that resulted in serious injuries to at least 33 inmates and seven correctional officers, including one inmate death.24
Weekly Divisional Reports from February 26, 2007 through June 17, 2007 show an average of 23.5 inmate fights and 3 incidents of "battery to staff with injury" per week at CCJ. Many of these incidents occurred in CCJfs maximum security divisions, where inmates should be supervised at the highest level, and extra precautions should be taken to minimize access to, and creation of, shanks and other weapons. Clearly CCJ cannot be expected to prevent all altercations between inmates. Nevertheless, the Constitution requires correctional officers and Cook County officials to take "reasonable steps to protect
23 CCJ1s latest attempt to deal with overcrowding involves a "hot bunking" pilot program whereby inmates volunteer to take turns using the same bed in eight-hour shifts. See Sheriff's Supplemental Report, Duran v. Dart, No. 74-C-2949, at 2 (N.D. Ill. Jan. 15, 2008). Although each inmate is reportedly using his or her own bedding, the hot bunking procedure could result in serious sanitation and infection control problems, as well as possible inmate-to-inmate intimidation regarding potential volunteers.
24 See e.q., William Lee, "Two Cook County Jail Inmates Were Stabbed During a Fracas in a Maximum-security Division Monday Night," Daily Southtown, May 2, 2006; Lori Rackl, "2 Inmates in Hospital After Jail Brawl," Chicaqo-Sun Times, Apr. 24, 2006; William Lee, "Seven Inmates at Division 11 are Injured by Homemade Knives in a Gang-Related Fight," Dailv Southtown, Apr. 24, 2006; Staff Writer, "Knife Fights in Cook County Jail Injure 17," Chicaqo Tribune, Mar. 13, 2006.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 29 of 99 PageID #:38
inmates from violence at the hands of other inmates." Goka v. Bobbitt, 862 F.2d 646, 649-50 (7th Cir. 1988). The level of inmate-on-inmateand inmate-on-staffviolence that is occurring within CCJ is so unacceptably high that it is clear that inmates are not adequately supervised, in accordance with generally accepted correctional standards. Notably, just as the Court and CCJ staff have recognized the shortage of staff supervision, inmates are also aware that they could engage in violence with little to no supervision. Much of the violence at CCJ involves group attacks, which reflect some degree of planning and coordination by the inmates, without the staff's knowledge or intervention.
As the following examples demonstrate, CCJ is not meeting its constitutional obligations to provide for the safety and well-being of its inmates:
1. On December 29, 2007, multiple inmates suffered stab wounds during a fight in a Division IX dayroom. Six inmates requidd treatment from outside hospitals and two inmates were admitted to the hospital with multiple stab wounds and other serious injuries. Officers were required to use Oleoresin Capsicum spray ('OC spray") to break up the fight. CCJ recovered four shanks, some of which measured six inches in length, and another weapon in the tier. Despite the severity of this incident, IAD did not open an investigation file.
2. On June 26, 2007, an officer delivering breakfast trays found inmate Louis J. unconscious on the floor of his cell in Division IX. Louis J. was admitted to the hospital for trauma and died on July 8, 2007, as a result of his injuries. Hospital records showed a hematoma with fractures and wounds to the face and head. Although the Incident Report related to this incident states that Louis J. may have suffered a seizure, Louis J.'s cellmate was promptly transferred to CCJrshighest level of disciplinary segregation, the Level IV Special Incarceration Unit in Division IX. However, CCJ could not produce a disciplinary citation, hearing record, or investigation documentation on the incident.25 Louis J.'s cellmate was still in the
25 We requested all documentation related to this incident on multiple occasions. We never received any disciplinary or investigation records. CCJ did not complete a mortality review for Louis J., allegedly because he was no longer in custody at the time of his death.

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Special Incarceration Unit a month after the incident, during our July 2007 site visit.
3. On June 26, 2007, officers noticed that several inmates from Tier 4B were running as they returned from the Division X gymnasium. Officers found several inmates with stab wounds and other injuries in the corner of the gymnasium. One inmate was hospitalized with a stab wound to the neck and another inmate had a broken jaw. The fight was apparently the result of different gang affiliations mixed within the tier. Upon investigating, officers recovered three shanks. CCJ placed the entire 48-inmate tier on extended lockdown from June 26 through July 8, 2007, wherein each inmate was allowed out of his cell for only one hour per day, and only one inmate was allowed out at a time. No other obvious precautions were taken to address the gang problem on the tier. When the lockdown ended on July 8, another fight broke out involving some of the same inmates and the same gangs as the June 26 incident. One inmate was stabbed and officers recovered another shank.
4. On June 20, 2007, inmates Auben J. and Sam D. suffered injuries to their heads and faces following a fight in the outdoor area of Tier A-H in Division-IX. Because no officers witnessed or responded to stop the fight, it was eventually broken up by another inmate, Roger R. Officers only learned of the fight after observing Auben J. bleeding from the head when he returned from exercise. Because Roger R. admitted that he helped separate the fighting inmates and injured Auben J. in doing so, he was transferred to disciplinary segregation along with Auben J. and Sam D.
5. On May 10, 2007, seven inmates were treated for stab wounds after a gang-related fight involving approximately 25 .inmates in the Division IX, Tier 3C, dayroom. Inmates Mark V., Alex W., and Arthur A. had to be transferred to outside hospitals for medical treatment. CCJ staff found a shank in the dayroom.
6. On December 5, 2006, 31-year-old Marcus K. was found dead in his cell. His cellmate was charged with first-degree murder for allegedly strangling Marcus K. after the two were heard arguing. The two men were
locked in their cell at the time, and other inmates in '

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 31 of 99 PageID #:40

the common area alerted a correctional officer that an inmate needed help during .the altercation.

7. On April 22, 2006, inmate Izzy J. suffered a fatal stab wound to the head during a gang-related fight involving approximately 20 inmates in Division XI. Six other inmates were hospitalized after the braw.1; five of the inmates were stabbed with shanks.

I
8. On April 2, 2006, inmates Tyson D. and Freddy R. were

seriously injured during a gang-related fight involving

at least six other inmates in Division XI. Both Tyson

D. and Freddy R. were admitted to the hospital with

1

,

multiple stab wounds to the back.

In addition to.the inmate-on-inmateviolence, CCJ1s security failings put staff in danger as well:

1. On March 22, 2007, maximum security inmate Reed W. stabbed a correctional officer, a nurse, a hospital patient, and a bus driver during an unsuccessful escape attempt at Stroger Hospital, where he had been taken for a doctor's appointment. CCJ officials reported that Reed W. may have smuggled a shank out of CCJ Division IX in his rectum.

2. On August 16, 2006, correctional officer Ben W. was hospitalized for five days and required 30 stitches after being attacked by inmate Daniel M. in Division V. The inmate was able to run from the scene before any other officers could come to Officer W.'s aid.

3. On April 15, 2006, six officers received medical treatment, and at least four inmates were hospitalized for stab wounds, after a multiple-inmate fight broke out in a Division XI dayroom. Officers recovered several wooden sticks and at least one metal shank following the fight.

b. Inadequate Security Staffing

As a result of insufficient security staffing, CCJ is not providing adequate supervision of the inmate housing areas. As discussed above, a major concern surrounding inmate supervision is the practice of 'cross watching." Cross watching refers to the practice of having one correctional officer simultaneously

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 32 of 99 PageID #:41
supervise two tiers of cells as opposed to one.26 The correctional officer monitors the second tier on camera while stationed in the first tier's control center. By policy, the officer supervising a housing unit is supposed to conduct security rounds inside the unit every 30 minutes, which allows him to check on inmates in their cells and in the shower and bathroom areas. These areas are not visible on the security monitors or from the officer's standard post inside unit's control center. However, if or when the officer conducts a security check inside the first housing unit, the second housing unit is unsupervised. If the officer leaves the control center of the first housing unit to conduct a check of the second housing unit, the inmates in the first housing unit can see that there is no officer supervising their actions.27 Although we recognize that CCJ has made efforts to increase staffing levels in housing units and decrease cross watching, we observed numerous instances of cross watching during our June and July 2007 visits to CCJ. The practice is highly utilized during lunch periods, but we also observed cross watching throughout the day.
As noted earlier, because inmates are aware when there is not an officer in the housing unit, there is a higher risk for illicit inmate behavior, including inmate assaults, production of weapons, and gang and drug activity. For example:
On May 15, 2007, an officer was cross watching two tiers in Division IX, a maximum security division. Inmate Carson T. was assaulted by five or six inmates in the tier dayroom. He received multiple wounds to his shoulders, back, face, and was admitted to the hospital. The cross watching officer did not notice anything amiss until he saw inmate Carson T. pacing by the tier door. CCJ documents noted that Carson T. had "injuries resulting from being attacked with a homemade knife" and that a "small piece of metal was sticking out [his] back." During the subsequent investigation, security staff found two shanks in the tier. No officer observed the dayroom assault.
26 Cross watching is prohibited by the Duran Consent Decree and the John Howard Association has cited CCJ for the practice, but it continues to occur. See 2007 Court Monitoring Report at 86.
27 The number of inmates per housing unit varies across divisions, but it is not unusual for one cross watching officer to be responsible for more than 90 inmates in two units.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 33 of 99 PageID #:42
2. On May 10, 2007, also in Division IX, an officer was cross watching two tiers when a disturbance involving 25 inmates occurred. Seven inmates received injuri'es including multiple lacerations and puncture wounds.
3. On December 24, 2006, the assigned officer was cross watching two tiers in Division VI when inmate George W. assaulted inmate Otis F., causing a head injury.
4. On July 25, 2006, inmate Andrew K. committed suicide in Division I while the assigned officer was cross watching two tiers. The Medical Examiner reported that inmates discovered Andrew hanging by the cell bars, alerted officers, untied his noose, and initiated chest compressions before staff intervened. Although staff reported that sight checks occurred in the tiers on a frequent basis, it is not clear if the officer actually saw Andrew in his cell at the times reported. Inexplicably, the CCJ investigation of the incident did not include the results of interviews of the other inmates who were present in the tier at the time of Andrew' s death.
5. On March 19, 2006, inmate John M. was attacked by two other inmates in Tier D-B of Division XI, which at the time was a maximum security division. Because the officer assigned to Tier D-B was at lunch, and the two closest officers were cross watching Tiers D-B and D-C and Tiers D-A and D-D, the officers had to wait for back-up to arrive before anyone could enter Tier D-B to break up the fight. John M. suffered two puncture wounds to his neck and one puncture wound under his arm. After the fight, officers recovered two steel shanks, a broken cane, and three razors from the tier.
c. Contraband and Vandalism
Another indicator of inadequate supervision is the amount of dangerous contraband that is being recovered from the housing units and the ease by which inmates can fabricate homemade weapons. Due to the dilapidated condition of scores of cells, shower areas, and various dayroom features, inmates have ample material for fabricating weapons, including floor tiles, metal from light fixtures, metal from the ventilation system, glass from cell light bulbs, electrical wiring, and plumbing fixtures. It is virtually impossible for any correctional facility to completely deter inmates from obtaining materials for weapons due to the condition of the physical plant, but the problem at CCJ is,

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 34 of 99 PageID #:43
further exacerbated by the lack of direct supervision in most of the divisions.
Even though the CCJ administration has recently made efforts to curtail the creation of shanks and other weapons through the establishment of a 'Weapons Committee," a severe contraband problem still exists. For example, IAD's Contraband Log reveals that, between January 1, 2007 and June 19, 2007, security staff found approximately 484 weapons and shanks. Many of these weapons and shanks were found in inmate cells and dayrooms after a stabbing incident. The Weekly Divisional Reports from February 26, 2007 through June 17, 2007 show an average of 23.5 shanks and 6.6 weapons found each week at CCJ. In just one week, April 2-8, 2007, CCJ staff recovered 55 shanks and 12 weapons. In 2006, IAD opened approximately 590 cases involving shanks, 77 involving weapons, and 115 cases involving other contraband. The number of weapons and shanks is extremely high, even considering CCJ1s large inmate population.
During our site visits, we noticed scores of opportunities for inmates to fabricate shanks and other weapons. We found broken and jagged floor tiles laying exposed in dayrooms without raising the notice of staff. In some instances, inmates are using the absence of ventilation grates in their cells to rig a "dumbwaiter" system that allows them to transmit drinking water between the housing unit's upper and lower tiers from within their locked cells. However, the inmates can also use these passageways to pass contraband. Shower and bathroom walls in the Residential Treatment Unit ("RTU") that had been damaged by inmate vandalism provided ample opportunity for weapons production and concealment of contraband. We observed numerous vandalized cell lighting fixtures and missing and vandalized cell vents, which are commonly used to create shanks. Inmates' access to the lighting fixtures can lead to additional dangers. For example, on June 14, 2007, an inmate attempted suicide by cutting himself with a broken light bulb.
In addition to the troubling, unchecked proliferation of weapons at CCJ, it is clear that there is a serious narcotics problem. Between January 1, 2007 and June 19, 2007, IAD opened approximately 110 cases related to narcotics/drugs. In 2006, IAD opened approximately 160 cases involving narcotics/drugs.
The lack of adequate supervision at CCJ is further highlighted by the frequent and flagrant rule violations that are evident in almost every tier throughout the facility, including special management units that should have a higher degree of supervision. For example:

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 35 of 99 PageID #:44
Scores of cells have been vandalized and are rife with gang and general graffiti.
Scores of cells contain homemade clothes lines. The hanging linens prevent adequate visibility into the cell. Also, the clothes lines can be used by inmates as potential weapons or suicide implements.
Small in-cell fires are common. Many inmates use the cell lighting fixtures as an ignition source for warming food and starting fires. Numerous inmates covered the cell light bulb with a milk carton that serves as a lamp shade and an ignition source. In scores of cells, the bottom bunk has evidence of having been heated. Inmates and staff reported that inmates use the bottom bunks as hot plates for warming food by setting a fire underneath them.
Scores of cells contain dozens of empty milk cartons and other stored debris that can be used by inmates for improper purposes and provide a potential fuel load in case of a fire.
Numerous shower areas have been vandalized, resulting in exposed ceilings and materials that can and are used to fabricate weapons.
Numerous inmates use extra blankets as carpets or room dividers for their cell, while other inmates claim a shortage of blankets.
Scores of cells, shower areas, bathrooms, and dayrooms have exposed electrical wiring.
8. Scores of vents, window sills, stairwells, and screens throughout the tiers are plugged and covered with debris.
9. As discussed below, many in-use cells are so unsanitary or have such severe maintenance problems that it is clear that adequate security checks are not occurring.
It is common for inmates to try to engage in vandalism or rule infractions, and CCJ could not be expected to prevent all such inmate activities. However, it is not generally accepted correctional practice to allow these violations to occur so flagrantly and with such prevalence throughout the facility.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 36 of 99 PageID #:45
The sheer frequency of these issues demonstrates that inadequate supervision is common at C C J .
d. Inadequate Visibility
Inmate supervision is further hampered by CCJ's physical layout, which does not allow for direct supervision in most divisions. With the exception of the Division I1 and RTU dormitory units, correctional officers are not stationed inside the housing units. In most divisions, the housing units are supervised by an officer from a tier control center or security entrance post that only allows for observation of the dayroom and some common areas of the housing unit. This is the case even in the special management units, such as disciplinary segregation and protective custody, which is a grossly atypical corrections practice. The officer cannot see into the individual cells while in the control center and is therefore required to conduct frequent physical checks of inmates in their cells. However, security check documentation at C C J is spotty. For example, during our on-site visits we discovered pre-recorded security checks on housing unit logs and also security checks that were suspiciously logged at precise intervals throughout a shift without any deviation. In addition, numerous inmates throughout the facility reported that officers commonly only enter the housing unit during shift change or meal times, but not on regular rounds throughout the day. This is not surprising, as a single officer may be cross watching two housing units simultaneously from one control center.
Even if security rounds within the housing units are occurring as scheduled, lack of visibility into cells is a major safety concern. Scores of cells are dark due to inoperable lighting fixtures, missing light bulbs, or inmate vandalism of lighting fixtures. We also observed the results of rampant vandalism of the lighting system in the RTU dormitory units, despite the fact that an officer is purportedly posted inside each RTU dormitory at all times. In fact, one RTU dormitory had no working lights and another had only two or three working lights, out of 24 light fixtures. Lack of operable lights makes the entire unit dangerous both for inmates and officers. This problem is compounded by the fact that correctional officers cannot replace broken or burned out light bulbs, but must issue a work order and wait for Facilities Management to handle the request. In addition, we observed many cells and shower areas with "privacy curtains" and with the celldoor windows obscured by cardboard, paper, towels, and other materials. It is very difficult, if not impossible, for officers to provide adequate safety and security checks of inmates when they cannot see into

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 37 of 99 PageID #:46

the cells and shower areas. Compounding the lack of adequate inmate supervision within the housing units is the fact that cells are not equipped with intercoms or emergency call buttons, which are useful safety and security features designed to allow for a locked inmate to alert an officer in an emergency situation. Intercoms or emergency call buttons are especially important for special management units, where the inmates spend approximately 23 hours of the day locked inside their cells, often alone.

Of particular concern for inmate and officer safety is the lack of visibility in the Special Incarceration Unit of Division IX. As these cells house CCJ1s highest risk offenders and inmates with demonstrated behavior problems, the celldoor windows have been modified to prevent inmates from throwing liquids or objects at officers. However, instead of installing a protective covering that would allow for observation, such as safety glass, CCJ welded a metal plate with small holes in it on to the cell windows in the Division IX Level 4 tier. As a result, it is virtually impossible to see into the cell, especially at night.

In addition to iriadequate interior security visibility, during a night time tour of CCJ, we observed approximately 22 external post and building lights that were not functioning in the area between Division I and Division V. This is unacceptable and a significant security risk.

I

e. Inadequate Security Policies and Procedures

At CCJ, each separate division has Standard Operating Procedures ("SOPS") that cover all the necessary components for a security program, such as key control, cell locking procedures, incident reporting, and search procedures. During our review, we found that while some CCJ policies and procedures were up to date, many were not. Generally accepted correctional practices require that post orders should be reviewed on a quarterly basis. CCJ policy requires that post orders be'reviewed annually. We reviewed the post orders available at various security posts . throughout CCJ and found many post orders that had not been reviewed in multiple years. For example, in Division XI, we inspected a manned gun tower. The post order for the tower was dated January 1996 and was last revised on January 15, 2003. In addition to being outdated, the post order did not contain essential information for an armed post, including instruction on when and under what circumstances the weapon should be used. CCJ is also lacking in proper policies regarding inventory of security equipment, including the newly.introducedOC spray, which could allow for unaccounted misuse by correctional
I

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 38 of 99 PageID #:47

officers. When post orders are not updated regularly and do not address vital information, facility practices will develop in an ad hoc nature and will not account for current needs. Outdated policies, procedures, and post orders are inconsistent with generally accepted correctional standards and contribute to a failure of the overall security system.

Although CCJ policies must adapt to some extent to account

for the different security levels and different physical layouts

in the various divisions, there is widespread policy variation

from division to division on issues ranging from the handling of

grievances to incident reporting. This can be confusing for

correctional officers, who rotate posts every 90 days and may be

transferred from one division to another without adequate

training on division-specific SOPS. Policy discrepancies abound

division to division, which result in widely different security

practices. There is no standardized format in use throughout CCJ

for division Roster Staffing Reports and Post Analysis Reports.

Even CCJ1s top level administration is unclear how security

procedures are implemented throughout the facility. For example,

a high level security official told us that each and every inmate

should be patted down when he or she returns from the recreation

yard. However, Division I supervisors reported that inmates are

only subjected to pat downs at random upon their return from the

yard.

,

A n additional area of policy concern is with regard to special management units, which include the Special Incarceration Units, disciplinary segregation, and protective custody units. Generally accepted correctional practices require that officers who are assigned to these types of units possess a higher level of detention experience, receive focused training in special management operations, and are regularly assigned to these units for stability purposes. Correctional officers in CCJ's special management units rotate on a regular basis and do not receive specialized training for working with high risk inmates. This practice should be changed at the policy level.

f. Disciplinary Process

CCJ operates the inmate discipline component with a policy and procedure that appears to be adequate and provides sufficient due process to inmates. However, we did note some concerns with regard to the disciplinary process. First, hearings are not consistently conducted in a private, confidential manner and secure setting in accordance with generally accepted correctional standards. During our observation of the disciplinary hearings in Division 11, 12 inmates were brought into a large room and

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 39 of 99 PageID #:48
seated together for their individual disciplinary hearings, including inmates whose disciplinary charges involved incidents of violence against each other. The proceedings were conducted within hearing of the other inmates. This process certainly presents safety and security issues because there may still be animosity between inmates who were involved in an altercation. For example, on July 26, 2007, two inmates began fighting during a disciplinary hearing in the Division VI library, and required medical care. Also, the victim may be reluctant to be truthful during the hearing for fear of retaliation by the aggressor. In addition, we noted that the statements made by the inmates during the hearing are written down by the disciplinary board in a very abbreviated fashion that may not adequately represent the inmates' statements.
Deficient Classification Procedures
All inmates admitted or discharged from CCJ are processed in the RCDC. The RCDC is located in the basement of Division V, and was originally designed as a storage area. Instead of storage, it holds several hundred inmates as they are strip searched, processed through booking, fingerprinted, photographed, screened for medical and mental health problems, and assigned to a bullpen until they can be transferred to their appropriate divisions. Almost every evening, the RCDC bullpens hold hundreds of inmates, for several hours at a time, who are crowded shoulder-to-shoulder behind chain link fences so tightly that there is insufficient space for them to sit or lie down. There is one female bathroom and only one male bathroom, with two toilets, and no hand washing facilities, for hundreds of male inmates to share.28 While the RCDC overflows with hundreds of inmates, a surprisingly small number of correctional officers attempt to perform a multitude of duties, including the supervision of inmates. In addition to the natural stress resulting from admission to jail, inmates upon booking, who may have been held for multiple days in various police departments before arriving at CCJ, can be medically and mentally unstable. Newly admitted inmates are very unpredictable. The overcrowded, disorganized, and understaffed RCDC is a major security and safety risk to staff and inmates.
28 On January 14, 2008, the Sheriff's Office sent us photographs of recent renovations to the RCDC bathroom, including six new sinks and five new urinals. This is a vast improvement, but the single bathroom and limited toilets is still problematic, given the immense number of inmates in the RCDC each evening.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 40 of 99 PageID #:49
The John Howard Association found the RCDC "grossly inadequate in size, design, and virtually every other re~pect."'~ We concur. The Sheriff's Office and the County concede that the RCDC physical plant is inadequate and we understand that funds have been allocated for construction of a new RCDC and RTU, but the new facility will not be completed until late 2009, at the earliest.30
Classification problems do not end with the physical plant of the RCDC. The Sheriff's Office admits that the present classification system is "extremely obsolete."31 The system was purchased in 1991 and last updated in 1993. It is an antiquated inmate tracking system that is incapable of tracking basic information, such as the number of empty beds in each CCJ division at any time. The RCDC Superintendent is required to make telephone calls on a constant basis to the other divisions in order to ascertain the bed availability. Although the RCDC Superintendent has access to e-mail, the superintendents of the other divisions do not.
The classification system contains provisions for initial custody assessment and for custody re-assessments. However, although CCJ uses a Special Incarceration Unit 'level system" to manage high risk inmates and security threat groups, that information is not contained within the classification policies and procedures manual.
Perhaps more troubling than the obsolete nature of the CCJ classification system is the fact that many supervisors do not understand how to properly utilize the system. Midway through our second site visit to CCJ, we learned that information on each inmate's classification status and history is readily available from terminals in every division. However, many CCJ supervisors and even division superintendents had previously reported to us that they could not access such information on the system. The superintendent who revealed the broader tracking capabilities to us acknowledged that many CCJ supervisors are not proficient with the CCJ system.
29 2007 Court Monitoring Report at 67.
30 President Todd H. Stroger and the Cook County Board of Commissioners' Status Report, Duran v. Dart, No. 74-C-2949, at 8 (N.D. Ill. June 11, 2007).
31 Sheriff's 2007 Status Report and Response to John Howard Association Court Monitoring Report, Duran v. Dart, No.
74-C-2949,at 22 (N.D. Ill. June 11, 2007).

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Given the high level of inmate assaults and gang-related violence at CCJ, it is clear that inadequacies of the classification system are contributing to CCJ1s security deficiencies.
4. Inmate Grievance Procedure
An inmate grievance system is a fundamental element of a functional jail system, intended to provide a mechanism for allowing inmates to raise conditions of confinement related concerns and issues to the administration. If viewed as credible by inmates, it can also serve as a source of intelligence to staff regarding potential security breaches as well as staff excessive force or other misconduct. The grievance system should be readily accessible to all inmates. Inmates should be able to file their grievances in a secure and confidential manner and without the threat of reprisals. Staff responsible for answering inmate grievances should do it in a responsive and prompt manner. Unfortunately, we noted a number of serious concerns with the inmate grievance process at CCJ.
The primary responsibility for coordinating and responding
. to inmate grievances lies with the Correctional Rehabilitation
Workers ("CRWs") Each of the approximately 40 CRWs, if evenly distributed throughout CCJ, has a caseload of well in excess of 200 inmates, which is extremely ambitious. Although management staff expect that the CRWs conduct at least two visits to each of their assigned units per week to collect grievances and to perform,other duties, this is not occurGing on a consistent basis. Moreover, numerous inmates complained that they do not have access to the CRWs (and consequently, the grievance process) if they are locked in their cells when the CRWs conduct rounds, which is a common occurrence.
At the divisional level and by divisional policy and procedure, there are supposed to be locked grievance boxes in the housing units for inmates to place their grievances in. The CRWs are supposed to collect the grievances from the locked boxes each weekday. However, the grievance system functions differently in practice, and varies from division to division and even from tier to tier. Although it is not reflected in the written policies, the prevailing current practice is 'for the inmate to give the completed grievance to the CRWs when they conduct rounds. Staff reported that inmate grievances are to be inserted in confidential envelopes and sealed by the inmate, which is also not written in the divisional policies. In some divisions, an inmate can also give the completed grievance to a security supervisor, who will record it in a log and give it to a CRW. In

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other divisions, security staff refuse to handle any grievance, to avoid conflicts and the appearance of impropriety. In yet another version, inmate grievance forms are kept and passed out only by the CRWs and completed forms are collected by the block sergeant and brought to the CRWsf office. Although most of the divisions are not using the grievance boxes, many staff members, including the Program Services Administrator, were under the impression that inmates were using the boxes. There is an extremely high level of confusion regarding the grievance policy and practice at all levels of CCJ.

In addition, access to grievance forms by inmates is a

I

universal problem. Although many management staff believe that

the grievance forms are available on the tiers, this is simply

not the case. The vast majority of the units that we visited

during our June and July 2007 site visits did not have inmate

I

grievance forms or confidential envelopes available on the

I

housing units. Grievances forms are not available in Spanish

I
I

language, despite the fact that many CCJ inmates can only speak, read, and understand the Spanish language.32

I

We also found that inmates believe the grievance process is unreliable and repeatedly complained about its effectiveness, with reason. For example, inmates stated that grievances related to the use of force generally result in one of two inadequate responses. Sometimes an investigator will speak to inmates after they file use of force grievances, but the inmates stated that they never heard back about their grievances. Most inmates complained that they heared nothing at all in response to a use of force grievance or received a summary denial. Inmate Byron S. filed a grievance approximately one month after an officer broke his jaw in January 2006. Thirteen days later he received a one sentence response to his grievance stating that there would be no IAD investigation because Byron had been found to have ''assaulted
and battered staff . . . as detainee was combative." In fact,
although the officer initially reported that he was attacked by inmates, the officer admitted he had fabricated the story weeks before Byron filed the grievance. IAD filed a complaint against the officer for falsification of a report, yet the response to Byron's grievance, over a month later, was factually inaccurate according to CCJfs own records. Moreover, the grievance did not trigger an investigation. CCJ opened the investigation seven months later, after Byron filed a lawsuit.

32 See Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d & sea.

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5. Access to Information
Generally accepted correctional practice requires that newly admitted inmates are given an opportunity to learn about the facility rules and regulations, services that are available, policies and procedures that affect the inmate, and facility schedules. Each inmate should receive a facility handbook, containing all the relevant information, and should have an opportunity to have the information explained to him or her if the inmate cannot read. Most facilities have a formal orientation procedure as a part of the intake processing. At CCJ, officers reported that they offer inmates a copy of the inmate handbook in the RCDC. There is no documentation as to whether a handbook is offered or accepted. Although there was a small stack of inmate handbooks behind a counter in the RCDC strip search area, we did not observe a single inmate of the hundreds present in the RCDC area with a CCJ handbook during either of our site visits.
B. INADEQUATE MEDICAL CARE
Jail officials are responsible for providing adequate medical care to inmates. Moreover, a jail may not deny or intentionally interfere with medical treatment. A delay in providing medical treatment may be so significant that it amounts to a denial of treatment. Our investigation revealed that medical care provided at CCJ falls below the constitutionally required standards of care. We found the following deficiencies: (1) inadequate medical staffing; (2) inadequate intake screening; (3) inadequate health assessments; (4) inadequate acute care; (5) inadequate chronic care; (6) inadequate emergency care; (7) inadequate record keeping; (8) inadequate medication administration; (9) inadequate management of communicable diseases; (10) inadequate access to medical care; (11) inadequate medical facilities; (12) inadequate dental care; and (13) inadequate quality assurance.
1. Inadequate Medical Staffinq
CCJ lacks the medical staff necessary to provide adequate medical services. Generally accepted correctional standards of care require that facilities maintain adequate staffing to provide inmates with necessary medical care. Many of the problems identified below are exacerbated by the inadequate medical staffing. In early 2007, there were significant health care cutbacks at CCJ, including 23 clinical positions (four physicians and three dentists), nine management positions, and 16 other health care positions. These cutbacks have severely

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 44 of 99 PageID #:53
impacted the quality and timeliness of medical care at CCJ. Most notably, the nursing staff shortages,'which have left many divisions understaffed during periods of the day, and the dental staff shortages have caused or aggravated inadequate medical services.
2. Inadequate Intake Screening
CCJ fails to adequately identify inmates' urgent and/or ongoing health needs through appropriate intake screening. Adequate intake screening is essential for ensuring that inmates are receiving proper care for acute or chronic needs. Generally accepted correctional medical standards require that incoming inmates be screened by staff trained to identify and triage serious medical needs, including drug and alcohol withdrawal, communicable diseases, acute or chronic needs, mental illness, and potential suicide risks. CCJ1s intake screening fails to identify such needs and increases the risk of serious harm.
At CCJ, correctional medical technicians are responsible for conducting intake screenings. If an inmate's intake screening is positive for a possible acute or chronic condition, the inmate should be referred to a physician assistant for an evaluation. Nationwide, more than 30 percent of inmates have acute or chronic conditions that would require a medical or mental health evaluation on the first day at a correctional facility.33 In contrast, only 15 percent of the 100 intake screening records we reviewed during our June 2007 on-site visit resulted in a referral for evaluation. During our July 2007 on-site visit, we reviewed 120 intake screening records and found that only six of the inmates were referred to the physician assistant. These numbers depart significantly from what would be expected in CCJ1s inmate population, which strongly suggests that the CCJ intake screening process is incomplete and inadequate.
Screenings take place in an area of the RCDC that is chaotic, noisy, and crowded. The screening interviews often occur while inmates are handcuffed together, resulting in a total lack of privacy, which compromises the quality of information received. Further, CCJ1s screening form is deficient because it lacks sufficiently specific questions regarding acute and chronic illnesses, including drug and alcohol withdrawal. We found several instances where acute and chronic medical needs were not
33 National Commission on Correctional Health Care, The
Health Status of Soon-to-be-ReleasedInmates: a Report to Consress (May 2002). http://www.ncchc.org/pubs/pubs_stbr.html.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 45 of 99 PageID #:54
recorded on intake. These practices contravene generally accepted correctional medical standards, and place inmates at significant risk of harm.
For example, we identified the 'following cases of intake screening deficiencies:
a. Nadia H. died in late 2006, one day after being booked into CCJ, likely of withdrawal syndrome.34 During intake, she reported a history of heroin addiction, yet staff failed to document her drug use and history of addiction. Despite knowledge that Nadia had a history of addiction, staff disregarded her emergent condition and placed her in general population. The next day she was found dead in her cell.
b. Julia G. was booked into CCJ in 2007 with a history of alcoholism and a dangerously high blood pressure. The screening process failed to identify that she was at risk of developing delirium tremens, a potentially life-threatening, but preventable, complication of alcohol withdrawal. Instead of evaluating and treating her medical condition, she was transferred to general population, where she developed delirium tremens and had to be admitted to the hospital. She also had comorbid hyperthyroidism, which should have been detected during the intake screening. Because of CCJ's inadequate screening, Julia was at a very high risk of death.
c. In June 2007, David M. was booked into CCJ with a history of heart disease, deep vein thrombosis, depression, and recent trauma. Despite his serious medical history, he was neither examined by a physician assistant nor did he receive any medical care. Even after informing CCJ personnel on several occasions that he was currently taking a prescription for Coumadin (a blood-thinner prescribed for those at high risk for a blood clot and for some heart conditions), it took staff over three weeks before David finally received his first dose of Coumadin.
34 We reviewed the medical records of 20 inmates seen by the physician assistants in the intake area on June 18, 2007, and found that none of the inmates were asked about a history of alcohol withdrawal syndrome, a life-threatening condition that is common among inmates.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 46 of 99 PageID #:55
d. In June 2007, Lyle P. was booked into CCJ. At intake, Lyle reported his HIV infection and his strong adherence to his medication regimen, but he did not receive his medication prescription. Nearly two weeks passed before he was finally seen by an infectious disease specialist. Because of the two week lapse in medication, the specialist chose to delay treatment, which further enhanced the risks for Lyle to develop potentially-fatal drug resistance.
e. During our July 2007 on-site visit, we encountered an inmate who suffered from a recent facial trauma, including redness, swelling, and abrasions on the left side of his face. He complained of visual disturbances and discomfort over the entire left side of his face during intake, yet he was not examined by medical staff. It was only after we brought his condition to CCJ personnel that he was re-evaluated by medical
staff .
3. Inadequate Health Assessments
I
CCJ does not give its inmates an adequate health assessment within a reasonable period after admission. The generally accepted standard of care is to conduct a health assessment within fourteen days of admission, or sooner when medically indicated. This assessment typically includes a review of intake information, a complete medical history, a physical examination, and screening for tuberculosis ("TB") and sexually transmitted
diseases ("STDs"). Appropriate and timely health assessments are
particularly critical should screening procedures fail to identify an inmate's serious health needs and improves the facility's ability to provide efficient and adequate care.
The great majority of inmates admitted to CCJ do not receive a health assessment within a reasonable period after admission. Many inmates never receive a physical examination at all. Even inmates who were appropriately referred to the physician assistants upon intake did not consistently receive appropriate referrals for follow-up or assessment.35 The necessity for a full health assessment is underscored by the grossly inadequate intake screening process. In addition to the risk to individual inmates with untreated conditions, CCJ1s failure to conduct health
35 The physician assistants in intake spend approximately five minutes per patient and conduct very cursory examinations without privacy or an appropriate facility.

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assessments puts all inmates 'and staff at risk from the spread of disease.
4. Inadequate Acute Care
CCJ fails to provide adequate and timely acute care to inmates with serious or potentially serious acute medical conditions. CCJ1s acute care services substantially depart from generally accepted correctional medical care standards. We identified grossly inadequate acute care that led to prolonged suffering and premature deaths of inmates at CCJ. Acute care was so deficient that inmates suffered needlessly because medical staff failed to ensure that inmates met scheduled appointments, failed to monitor acute conditions, and failed to timely treat inmatesf conditions. We found numerous instances where CCJ1s failure to adequately assess and treat inmates likely contributed to preventable deaths, amputation, hospitalizations, and unnecessary harm.36
The following examples highlight CCJ1s deficiencies in providing acute care:
a. In early 2006, Gloria D. died after not receiving adequate care for an emergent and life threatening condition. Gloria, who suffered from human immunodeficiency virus ("HIV"),was admitted to CCJ in early 2006. After one month in the facility, staff ordered an x-ray after Gloria complained of persistent cough and shortness of breath. Although her x-ray was abnormal, Gloria did not receive any follow up care. Less than three weeks after her abnormal x-ray, Gloria developed a fever, t a ~ h y c a r d i a ,a~nd~ low oxygen saturation. Gloria was hospitalized and died of untreated Pneumocystis ~arinii.~'

36 Our medical chart review was hampered by CCJ1s highly disorganized and incomplete medical records. For example, 72 percent of the records we requested for inmates sent to hospital emergency rooms were unavailable. While the medical records deficiencies hindered our review, we were still able to document serious lapses in medical care.

37

Tachycardia is a rapid heart rate, over 100 beats a

minute, which can be caused by cardiac arrhythmia.

38 Pneumocystis carinii is an opportunistic but preventable infection that occurs in immunosuppressed populations, primarily HIV patients with advanced infection.

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b. In July 2006, Manuel M. was admitted to CCJ with a life-threatening blood pressure reading, an elevated pulse, and a history of alcohol use. Although he was medicated and monitored daily for hypertension, he was not treated for alcohol withdrawal and, on his third day at CCJ, exhibited tremors and an altered thought process! signs of delirium tremens. He should have been hospitalized at this point, but was not. On his sixth day at CCJ, when his blood pressure decreased some from its previously high levels, he was put in general population. He was never treated for delirium tremens and committed suicide while delirious.
c. In August 2006, inmate Aaron B.'s leg was amputated as a result of a bone infection resulting from CCJ's failure to provide adequate acute care. On August 8, 2006, Aaron was admitted to CCJ. He arrived at CCJ with a soft cast on his leg. Medical staff removed the soft cast and replaced it with a hard cast. Aaron complained of constant pain for nearly a week before he was finally seen by a physician on August 14. The physician scheduled an immediate orthopedist appointment for August 16. Unfortunately, Aaron never saw the orthopedist because the orthopedist refused to treat Aaron without his medical chart, which CCJ staff did,not provide. After complaining of discomfort and a malodorous discharge dripping from his hard cast, on August 31, he was admitted to Cermak infirmary with osteomyelitis (an acute or chronic inflammatory process of the bone). His leg was later amputated because the severe infection had destroyed substantial soft tissue.
d. In late 2006, Aidan A. died after suffering from sepsis.39 He was admitted to CCJ after suffering from a gunshot wound in his arm. His wound was surgically repaired and he had metal inserted in his arm to set the bone. The orthopedist scheduled an appointment so that the metal insert could be removed, but CCJ failed to take him to the hospital for his scheduled appointment. After seven weeks at CCJ, Aidan developed a deep tissue infection which elevated his respiratory rate and his pulse rate became dangerously high. By the time he was finally taken to the hospital, it was too late to contain the infection and Aidan died at the
39 Sepsis is the presence of bacteria or other infectious organisms or their toxins in the blood or in other tissue.

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hospital.of sepsis two months after his admission to CCJ. This was a preventable death.
e. Five days after his 2007 intake to CCJ, Henry H. had a new, on-set seizure and suffered a fractured jaw during the incident. It took six days for him to be seen by an oral surgeon and he was never evaluated for the cause of his seizure, as he should have been.
5. Inadequate Chronic Care
CCJ fails to provide adequate care to inmates with serious medical needs that require monitoring and follow-up medical care. Inmates who suffer from chronic medical illnesses must be regularly monitored by medical professionals to prevent the progression of their illnesses. Monitoring should occur on a regular basis to ensure that symptoms are under control and that medications are appropriate based on generally accepted correctional medical standards. However, we found that CCJ was deficient in ensuring that patients are seen on a regular basis, that medications are timely distributed, and that inmates are monitored and treated to prevent the progression of illnesses.
Specifically, in examining a sampling of medical records of inmates with chronic conditions, we found the following instances of deficient chronic care:
a. In reviewing the records of ten CCJ inmates with diabetes, we looked for seven nationally accepted
intervention^.^' Inadequately monitored diabetes can
lead to stroke, vision loss, diseases that effect the feet and muscles, kidney damage, coma, and death. In a gross departure from generally accepted correctional standards, none had a documented urinary microalbumin within the last 12 months; only two had a measurement of Alc hemoglobin within the past three months; four had a cholesterol measurement within past year; two were on aspirin prophylaxis; and two had a dilated retina exam. Our review of these files revealed that CCJ was not adequately monitoring these inmates through
4 0 These interventions are: measurement of sugar levels upon intake, measurement of urinary microalbumin, dilated examination of the retina, cholesterol measurement, measurement of Alc hemoglobin, chronic care visit with physician, and aspirin therapy.

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chronic care visits or consistently screening them from the conditions that they are at risk of developing.
b. We reviewed the treatment of 14 inmates suffering from moderate or severe asthma. Chronic follow-up care and regular monitoring of peak expiratory flow (a test that measures how well the airways are working) are critical in the proper care for persons with asthma. We found five of the 14 inmates had not been seen for chronic care within the last three months and only seven of the 14 had any measurement of their peak expiratory flow. We also requested records of 13 inmates seen in the Cermak emergency room for acute asthma between March 5 and May 2, 2007. None of these patients had follow-up to see if they were improving.41
c. Similarly, we requested the records of 15 inmates at the facility who are on the blood thinner Coumadin. This medication has very narrow therapeutic range; if an inmate is given too little, the medication will be ineffective, but if the medication is given too much, he or she will experience substantial detrimental effects. Accordingly, frequent measurement of the blood-clotting ability of patients taking Coumadin is critical. Of the records we requested, two were lost, one inmate was not scheduled for follow up for eight weeks, instead of the typical one to two weeks, and another inmate did not have necessary laboratory tests at intake. Inmates who are taking Coumadin but who are not monitored appropriately are placed at risk for a potentially life-threatening blood clot or a hemorrhage.
d. We also reviewed the records of five paraplegic inmates who suffered skin breakdowns, skin ulcers (bed sores), or wound infections. Our expert consultant found patterns of egregious failures of care regarding wound care in each of these cases. In one startling example, we reviewed the chart of inmate Wallace G., who suffered a skin breakdown. An x-ray revealed that his initial skin breakdown caused a soft tissue infection which likely caused a bone infection. Despite the abnormal x-ray, we were unable to find any follow-up care, treatment for the condition, or assessment by the
41 Only 23 percent of the records requested were available and only one of those charts contained the emergency room record.

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physician. These failures are gross deviations from generally accepted correctional medical standards.42
6. Inadequate Emersency Care
5
CCJ fails to provide adequate emergency care. We observed an emergent incident during July 2007 on-site visit, when we encountered a male inmate who was known by CCJ staff to have a history of heart disease. While we were on his housing unit, inmate Mitchell H. experienced severe heart complications and lost consciousness. Although the dispensary nurse responded to the emergency call, it took 15 minutes for the ambulance and EMT to arrive. While the dispensary nurse was struggling to revive Mitchell, the EMTs were chatting and inattentive to Mitchell's needs. After nearly 45 minutes of suffering severe chest pains, Mitchell was finally placed in the ambulance. CCJ's slow response does not comport with generally accepted correctional medical standards and placed this inmate at risk of serious harm
We found additional instances of deficient emergency care that put inmates' health and lives at risk. As part of our review, we randomly selected five inmates who were seen in the Cermak emergency room for alcohol withdrawal symptoms in the spring of 2007 and concluded that CCJ1s treatment and assessment was deficient in four out of five cases. Two of the inmates were sent to the emergency room because of their significant elevations of blood pressure. In both cases, CCJ staff neither treated their high blood pressure nor adequately monitored their condition. Rather, CCJ sent both inmates back to general population without a thorough examination. Two other inmates were seen in the emergency room, but we were unable to find emergency room notes that documented any treatment.43 The last inmate received no treatment because he suffered from asthma and did not require treatment for alcohol withdrawal.
7. Inadequate Medication Administration
We found numerous systemic problems with medication administration and management. CCJ frequently fails to:
42 Our expert consultant advised CCJ of this patient's inadequate care during our July 27, 2007 exit conference.
43 - CCJ has a responsibility to obtain discharge summaries or notes from the hospital when inmates are treated at outside facilities in order to adequately assess and treat inmates upon their return to CCJ.

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(1) verify identification oi inmates receiving and ingesting medication; 2) provide critical medications to inmates without delay or lapses; and (3) maintain inmate medication administration records ("MARS") concurrently with distribution.
Generally accepted correctional medical standards require that facilities administer medication and maintain adequate medication records to meet the medical needs of the inmates and to prevent medication errors and other risks of harm. Regular and systematic reviews of medication usage is also required to ensure that each inmate's prescribed medication regimen continues to be appropriate and effective for his or her condition.
During our on-site visits, we observed the distribution of medication in each of the CCJ divisions. In every instance, we found nurses throughout the facility who failed to verify inmates' identification before administering medication. This deficient practice increases the chances of dispensing medications to the wrong inmate or dispensing medication to an inmate who may have an adverse reaction to medication. Also problematic was the failure of nursing staff to observe inmates swallowing prescribed medication. This failure prevents nursing staff from accurately recording administered medications and creates an unsafe and potentially dangerous environment where medication could be hoarded, sold, or result in overdoses. The nurses1 failure to verify identification and observe inmates swallowing medications is inconsistent with generally accepted professional standards of correctional medical care and greatly increases the risks for error and harm.
Our investigation also revealed significant delays, errors, and lapses in medication administration, all of which have contributed to needless suffering and inmate hospitalizations. The following examples illustrated the medication administration deficiencies:
a. As discussed above, David M. was booked into CCJ in June 2007 with a prescription for the blood thinner Coumadin, but there was a 22-day delay before he finally received his first dose of Coumadin.
b. In May 2007, Roy H. was booked into CCJ. He was admitted after a kidney transplant. He was prescribed medication to prevent his body's rejection of his kidney transplant. After 16 days without his prescribed medication, he had to be hospitalized because his body began to reject his kidney and he

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developed metabolic acidosis, a potentially life-threatening condition.44
c. In 2007, Gregory T. was booked into CCJ after a hospitalization for deep vein thrombosis. Although he had a prescription for Coumadin, CCJ staff failed to order his prescription. For nearly 20 days, he needles~l~suffered.He developed a blood clot in his leg and had to be hospitalized because of CCJ1s failure to order his prescribed medication.
d. In 2007, Stella R. had a prescription for Coumadin and a prescription for hypertension medication, yet CCJ staff failed to order her prescriptions. Stella went nearly 20 days without her prescriptions. It was only after we brought this medication error to CCJ1s attention that Stella had her prescriptions ordered.
e. In 2007, Rebecca N., an HIV-positive inmate, had a prescription for antiretroviral medication, but CCJ staff failed to administer her medication daily as prescribed. There was a five-day lapse in her medication, which is especially dangerous for inmates with HIV.
f. In 2007, Grant P. suffered head trauma during seizure, which was likely caused by his not receiving 11 of his 3 1 prescribed doses of his anticonvulsant medication.
We also found deficiencies in CCJ1s MARs. Contrary to generally accepted correctional standards, numerous MARs were not contemporaneously completed or signed as medication was distributed. CCJ medical staff often left records blank or failed to log critical clinical information upon distribution of medication to inmates. We spoke with a medication technician who told us that because of staffing problems in several divisions it was virtually impossible to distribute medications and document MARs at the same time. This -practice is inconsistent with generally accepted professional standards of correctional medical care and greatly increase the risk of error.
We also reviewed a sampling of MARs during our on-site visits and found that approximately 15 percent of the MARs were blank which made it difficult to determine if inmates were receiving medications as prescribed. In Division IV, we found
44 Metabolic acidosis is a clinical disturbance characterized by a relative increase in total body acid.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 54 of 99 PageID #:63
particularly high level of blank MARs. When we spoke to the nursing staff on th6 division, we learned that Division IV was severely understaffed. Further, we learned that staffing shortages had resulted in the division and nurses being unable to dispense medications in the afternoon or evening. Inmates were forced wait until the morning before they were able to get their medications. Similarly in Division 111, we learned that medications were not delivered because of staffing shortages and inmates were not receiving medications as prescribed. Blank MARs are indicative of inadequate training, supervision, and staffing.
8. Inadequate Infectious Disease Control
CCJ fails to adequately treat, contain, and manage infectious disease. This failure is dangerous and places inmates, staff, and the community at unnecessary risk of serious health problems. CCJ1s management of TB, Methicillin-resistant Staphylococcus aureus ("MRSA"),45and other infectious diseases deviates from generally accepted correctional medical standards. Inmates with infectious diseases are not appropriately contained, treated, or managed. The overcrowding, poor ventilation, and constant exposure of inmates to each other and CCJ staff are conditions conducive to the spread of disease. CCJfs containment and management of infectious disease substantially departs from generally accepted correctional medical standards.
CCJ fails to ensure adequate containment of TB. Once TB has been identified, treatment must be initiated and monitored. Inmates believed to have infectious TB should be placed in specialized respiratory isolation ('negative pressure") rooms to reduce the risk of transmission through airborne particles. Isolation rooms are essential to the prevention of contagion. These isolation rooms should be tested to ensure proper ventilation. In addition, staff who are potentially exposed.to the risk should wear masks and be trained in the use of specialized respirators. We found that CCJ does not comply with these generally accepted correctional standards.
The most egregious example of CCJ1s failure to provide adequate containment of TB is inmate Wallace G. Wallace was housed in a respiratory isolation room because of his abnormal chest x-ray and a history of TB. The room purportedly had negative pressure to contain any TB organisms. However, we
45 MRSA is a potentially dangerous drug-resistant bacteria that can cause serious systemic illness, permanent disfigurement, and death.

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inspected the respiratory isolation room and discovered that the room did not contain negative pressure. A correctional officer was stationed outside the hallway to the negative pressure rooms, in order to ensure that people entering the area wore proper masks, but the doors to the area were propped open. Immediately following our discovery of the possible inadequate containment, we informed CCJ personnel of our finding and the potential health risks. CCJ staff later moved Wallace to another respiratory isolation room that contained negative pressure.
Thereafter, we inquired into whether CCJ was following the Centers for Disease Control and Prevention's recommendations for containment of TB. The recommendations require facilities to check respiratory isolation rooms monthly, and daily when rooms are occupied.46 We found that neither CCJ, Cermak, nor Facilities Management Department inspect the isolation rooms. This oversight exposes staff and other inmates to a high risk of TB infection.
Similarly, CCJ fails to provide adequate management of skin infections. Consistent with generally accepted correctional practices, jails should adopt a skin infection control plan to guide the prevention of transmission of skin infections, including drug-resistant infections such as MRSA. MRSA transmission can be prevented by early identification, effective treatment, wound care, follow-up, environmental controls, and efficient laundry practices. We found serious deficiencies in these critical areas at CCJ.
CCJ lacks an adequate tracking system to ensure that skin infections are properly treated. We learned that CCJ had a nurse practitioner responsible for wound care and tracking patients with skin infections, but she did not record any of her findings in inmates' medical records. Without an adequate tracking system, inmates with infections are not properly treated and the risk of transmission increases significantly. Similarly, we found that the CCJ laboratory did not report diagnostic cultures of skin infections to the nurse practitioner. A culture, which is an examination of a sampling of cells taken from the affected area, may be done to identify the microorganism causing the skin infection and to determine the antibiotic or other treatment that will effectively treat it. Without wound cultures, it is impossible to recommend appropriate antibiotics and increases the risks of harm.
46 http://www. cdc .gov/mmwr/PDF/rr/rr5509.pdf

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Laundry is also an important component to prevent the transmission of infection. Inmates should have access to clean underwear and regular changes of uniform. CCJ launders inmatesf clothing once per week, thereby increasing the risk of infection transmission. Inmates informed us that the only way to maintain clean underwear is to wash it themselves in sinks and toilets in the cell area. We observed uniforms, underwear, and linen hanging to dry throughout the cell area and on railings and dayroom window ledges on every division. These deficient practices greatly increase the risk of intramural transmission of skin infections.
9. Inadequate R e c o r d K e e p i n q
CCJ fails to maintain complete, accurate, readily accessible, and systematically organized medical records. CCJ lacks an adequate medical records system to ensure that inmates' records are correct and accessible so that physicians can provide appropriate care.
CCJ's medical records system is strained and overflowing with unfiled and inaccurate medical records. For example, there is a three month backlog of unfiled medical records in the central medical records room; a two month backlog of unfiled emergency room records; and a three to 14 month filing back log of medical records in various CCJ divisions. The backlog of unfiled records seriously interferes with the continuity and coordination of care at CCJ. This inefficient filing system greatly increases the risk of error in treatment, assessment, and care. Further, the current system does not facilitate a system for coordinated treatment by multiple providers because inmates' records are not accurate, organized or timely filed.
We found records throughout the facility with critical medical information missing. For example, as discussed above, although inmate Aaron B. was scheduled to see the orthopedist for his serious knee injury, the physician refused to treat Aaron because CCJ could not find his medical chart. Aaron's leg was subsequently amputated because of a serious infection that developed due to inadequate care resulting from a chart that was missing in the medical record.
The inadequate record system is further impeded by clinicians who created 'shadow charts." Physicians kept lists, logs, or filed copies of progress notes and diagnostic reports their desks so that they could properly monitor their patients' progress. While the concept of creating shadow charts might se to enhance continuity of care, they actually create another

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barrier for maintaining accurate, complete, and accessible medical records. In most instances, physicians maintained notes, lists, and logs that were not updated in central records, which further created a gap in maintaining complete records.

Our investigation also revealed that medical records were not readily accessible. For example, we found that clinicians did not have access to inmates1 records maintained in the divisions after 3:00 p.m. because the medical records rooms were locked at that time due to staffing problems. This lack of medical continuity and coordination of care seriously interferes with the clinician's ability to manage medical emergencies outside of the Cermak units.

I i

10. Inadequate Access to Medical Care

The CCJ sick call process fails to provide adequate access to medical care. CCJ inmates access medical care by completing sick call requests. Although CCJ correctional staff are responsible for collecting sick call requests, inmates reportedly make multiple requests before receiving medical care. Our review of medical records confirmed that many inmates made several requests for care before receiving treatment. For example, on July 25, 2007, inmate Jackson E. requested medical treatment for staples that had been left in his scalp and sutures that had been left in his arm. Although he made several requests to have the staples and sutures removed, he did not receive treatment, even after our consultant alerted CCJ staff to his condition. 'He reportedly was placed in lock down for ten days for making repeated requests for medical care. It is inappropriate to punish inmates for requesting medical care. Similarly, inmate Donald C. made repeated unanswered requests for medical care for eye hemorrhages and lacerations he sustained in an altercation with custody staff.

Also of concern, inmates reported that they were limited in their ability to access medical care by the practice of extended half-tier lockdowns, discussed above. When inmates are confined , to their cells for extended periods, they have limited access to custody staff and can be denied access to medical and mental health care. For example, inmate Chester H. reported that he had a seizure during the 26-hour lock down period and he was unable to receive medical care and was unable to attract the attention of CCJ personnel. He needlessly suffered while he waited for medical care. Because the nurses do not go onto the units to deliver medications t'o inmates who are locked in their cells, inmates who are on lockdown status during medication administration do not receive their prescribed medications. The

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extended lockdowns interfere with implementation of prescribed treatment plans and continuity of care for inmates.
11. Inadequate Medical Facilities
Medical facilities at CCJ lack adequate space, privacy, lighting, and sanitation to provide inmates with medical care consistent with generally accepted correctional standards. Approximately 300 inmates receive face-to-face medical care daily.
Inadequate space is especially significant because it limits CCJ1s ability to provide medical services such as intake screenings, sick calls, and health assessments as well as care for inmates with specialty, chronic, and acute needs. The RCDC intake area is inadequately equipped to manage the daily volume of inmates during the essential intake screening process. The area is constantly congested and overcrowded.
~ e n e r a l la~ccepted professional standards of cprrectional medical care require that for a proper clinical evaluation inmates be examined in a clean and private setting with sufficient lighting and access to necessary diagnostic tools. We found mouse droppings in dispensaries and medication rooms throughout the facility. Moreover, some of these rooms lacked accessible hand-washing sinks or disinfectant, and contained unsecured syringes and other sharp implements, which can be potentially dangerous. Further, the floors and work surfaces of all of the medical units and intake screening area were filthy.
12. Inadequate Dental Care
CCJ fails to provide adequate dental care to its inmates. Dental care is an important component of overall inmate health care. Poor oral health has been linked to numerous systemic diseases. Contrary to generally accepted correctional standards, dental care at CCJ is not timely and does not include immediate access for painful or urgent conditions. During our June 2007 on-site visit, we found that there was only one dentist responsible for over 9,500 inmates.47 We further learned that the dentist was unable to perform any restorative care. The dentist's services were limited to extractions and it usually takes about two weeks before the dentist was able to perform any necessary follow-up care. More alarming, we learned that over 25
47 Three dentists, one dental hygienist, and seven fulltime equivalent dental assistants were cut in February 2007.

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percent of the extractions performed at CCJ resulted in chronic infections such as osteitis (inflammation/disease of the bone) or dry sockets.
We also found that the dentist typically was unable to treat inmates with serious or urgent dental needs. We found many instances where inmates complained of tooth abscesses, but the dentist was unavailable to treat their serious dental needs. For example, inmate Derek B. was admitted to CCJ on June 17, 2007, with a tooth abscess. Although Derek requested dental care, the CCJ dentist did not provide treatment for his tooth abscess. Without proper treatment, Derek is at risk of serious deep tissue infection, pneumonia, sepsis, septic shock, and possibly death.
As a result of the dentist's inability to treat serious dental needs, the Cermak emergency room and sick call are inundated with dental emergencies. Despite having Cermak physicians treat these serious dental emergencies, inmates continue to suffer needlessly because they do not receive appropriate follow-up care.
13. Inadequate Quality Assurance and Performance Measurement
CCJ fails to engage in consistent, effective quality assurance reviews in order to monitor and assess the quality of medical care offered at the facility. An adequate quality assurance and performance measurement instrument is necessary to examine the effectiveness of health care delivered at CCJ, to discuss medical care results, and to implement corrective action so that the quality of care is improved. During our on-site visi,ts,we found that CCJ had discontinued many of its performance measurements in February 2007 because CCJ lost accreditation by the National Commission on Correctional Health Care. As a result, CCJ discontinued its review of chronic disease care, acute and chronic care, completion of treatment for STDs, and access to care. Performance measurements are a critical component to ensure that polices and procedures are in place and to ensure adequate care. Without performance measures, the quality of medical care will suffer.
We also found that CCJ failed to conduct self-critical mortality reviews. Our expert reviewed mortality reviews and autopsies of 13 inmates who died while in custody at CCJ and found that none of the mortality reviews were self-critical. The absence of self-critical review creates a barrier for proper review that will ensure that proper policies and procedures are in place to correct failures and ensure adequate care, prospectively.

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Finally, staff involved in the inmate grievance process are frustrated that once a medical or mental health related grievance is referred to Cermak, a response is not forthcoming. The inmate grievance system should alert medical staff to possible weaknesses in the provision of medical care. We reviewed numerous grievance files that alleged the need for medical services, some of an emergent nature, that showed a referral to Cermak, but contained no actual response to the grievance. For example, inmate Steve S. filed a grievance on March 19, 2007 alleging that he was taken off his psychotropic medication without seeing a doctor, that he had been experiencing nightmares that prevented him from sleeping at night, that he was hearing voices, and that he was contemplating taking his own life and desperately needed help. The CRW acknowledged receipt of the grievance on March 23, 2007, but did not mark the grievance as an emergency and referred the grievance to Cermak with a statement that Steve S. merely alleged he was not getting proper medical attention. On April 2, 2007, Steve S. received a response stating, "Referred to Mental Health Services." The grievance file does not contain any information~indicatingwhether Steve S. ever received mental health treatment.
C. INADEQUATE MENTAL HEALTH CARE
CCJ fails to provide inmates with adequate mental health care that complies with constitutional standards. CCJ fails to address the specific needs of inmates with mental illness, including: (1) failure to timely and appropriately evaluate inmates for treatment; (2) inadequate assessment and treatment; (3) inadequate psychotherapeutic medication administration; and (4) inadequate suicide prevention.
Mental health services at CCJ are provided through a combination of County Cermak employees and a contract with the Isaac Ray Center ("IRCN) for psychiatric services. Cermak mental health services are directed by a Chief Psychologist who supervises a staff of approximately 50 individuals, including two medical social workers, three activity therapists, one mental health specialist supervisor, and approximately 40 Mental Health
Specialists ("MHSsU). County mental health services have
recently experienced specific cuts in staffing. The result is an inadequate number of trained staff to provide adequate programming and coverage in the mental health areas.
1. Failure to Timely and Appropriately Evaluate Inmates
CCJ fails to properly .dentify inmates with mental illness through adequate screening Adequate screening of incoming

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detainees for mental health care needs is instrumental to a facility's ability to identify inmates in need of mental health services, to provide appropriate mental health care, and to reduce potential harm to those whose conditions would otherwise go unrecognized. Mental health screening should comport with generally accepted correctional standards of care to aid in classification, identification of emergent mental health care needs, provision of continuous care, and management of medication.
Follow-up of known or new mental health problems is a key focus of intake screening. Mental health screening information should be incorporated into an inmate's medical record. This ensures the prompt continuation of necessary medication for all inmates with chronic or newly identified mental health conditions. Persons with potentially serious and/or chronic mental health illness (i.e., active psychosis, suicidal ideation) should be referred from screening for prompt mental health evaluations and examinations by a psychiatrist.
As indicated, CCJ1s medical screening and follow-up care procedures deny necessary care to inmates. The policy governing the CCJ mental health screening process is completely inadequate. Insufficiently trained MHSs perform mental health initial intake screening at CCJ. This screening is not accomplished under appropriate medical supervision. The system allows technicians, who are not adequately or appropriately trained in detecting mental illness, to query inmates and detainees regarding their mental health history.
For mental health screening, CCJ staff utilize a form entitled "Department of Mental Health Services Brief Primary Psychological Screening Tool" which is not then incorporated into the medical record. This is a one page form that is used to collect brief demographic information and answers to 11 general questions. No mental status exam is completed at that time. At the end of this brief interview, which lasts for less than five minutes, the MHS makes a decision whether to reger the inmate to general population, refer the inmate for admission to psychiatric services, or to conduct a secondary interview. The screeners do not ask questions beyond those on the form, and do not appear to understand when additional questions were indicated or what those questions might be, especially relating in the area of assessment of suicide risk. Thus, mental health symptomatology that is associated with past hospitalizations, current treatment, or suicidal ideation, is unlikely to be uncovered.

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Consequently, our expert consultant found that less than five percent of inmates screened are identified as having psychiatric problems. The County's Director of Psychiatric Services acknowledged that the screening process was flawed and one would expect the percentage of inmates identified with psychiatric problems to be as much as ten percent. No psychiatrists are assigned to supervise or support the RCDC intake area where the initial mental health screening is conducted. In addition, we found that even for those inmates who screen positively for serious mental illness, the subsequent referral process to mental health treatment providers is flawed.
2. Inadequate Assessment and Treatment
CCJ fails to appropriately assess and treat inmates with mental illness, including those inmates on the acute care units and in the RTU. Our investigation revealed two principal problems. The first is the lack of attention to past mental health treatment records including previous psychiatric hospitalizations. Virtually no collateral mental health care information is requested or utilized in the assessment process. The second problem is that medical information already collected is not available for review or utilization in the continued assessment and treatment process. Our review of records indicates that this leads to multiple, often conflicting diagnoses, potential over prescription of antipsychotic and antidepressant medications, and medication dose adjustments without clear rationale. These failures have resulted in mental health deterioration and unnecessary suffering.
We noted that there are significant problems with the mental health treatment records. CCJ fails to maintain complete, accurate, and systematically organized mental health treatment records. CCJ's medical and mental health records system is completely inadequate and mismanaged. We observed numerous incomplete, unfiled, and inaccurate records. This flawed record system greatly increases the risk of error in assessment, treatment, and care. The County Director of Psychiatric Services described the medical record operation within CCJ as "grossly inadequate."
The following examples are illustrative of the assessment and treatment failures at CCJ:
a. Seth P. was seen for a psychiatric consult during our July 2007 on-site visit. Seth had been admitted to CCJ three to four weeks prior to the consult and, after initial screening, had been placed in the general

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population. No records were available or requested48at the time of the consult. The psychiatrist evaluated Seth and assessed him as exhibiting grandiose thinking and hyperactivity, prescribed medications, and ordered Seth to be admitted to CCJrs acute psychiatric unit for further evaluation. Immediately following the psychiatric consult, Seth was sent to an outside emergency room for evaluation for a possible fracture of his right hand. Upon his return to CCJ, the intake MHS14' who was not aware of the recent psychiatric assessment due to the inadequate record keeping, determined independently that Seth was to be admitted to the general population. The result was that Seth received no further psychiatric evaluation and did not receive the prescribed antipsychotic medication ordered by the psychiatrist.50
Melanie 0. had a miscarriage at CCJ on May 25, 2007, was depressed, and had not received any psychiatric follow-up even though she was taking psychotropic medications. During our June 2007 on-site visit, we observed Melanie sitting in a hallway, having what proved to be an acute allergic reaction. No medical records for Melanie were available at that time. Eventually, Melanie's medical record was obtained and the record reflected that she had been sent to the emergency room two days earlier because of symptoms of allergic drug reaction. Medication was prescribed, but Melanie had not received the medication because there was no record of the prescription order from the hospital. No medical evaluation had been completed to
48 The Director of Psychiatric Services indicated that to request such records would be fruitless. When we insisted that the records be requested, none were available nor could they be located. Eventually Seth P.'s medical records were located, two days later, and the record was found to be incomplete.
49 Each time an inmate is transferred or leaves the facility for a consult, he is returned to the intake area for a housing classification. In this case, the housing classification was conducted by the intake MHS.
50 The psychiatrist was not aware of the mixup and the situation was rectified only after we brought the matter to his attention. The Director of Psychiatric Services indicated that this was typical of what happened at CCJ on a daily basis.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 64 of 99 PageID #:73
determine the cause of her allergic reaction and no psychiatric assessment of her mental state occurred.
c. Kyle N., who had been assigne'd to CCJ1s acute psychiatric unit, had a medical record which contained misfiled medical record information belonging to another inmate.
d. Anthony G. was housed on a Division IX Segregation unit, with limited out-of-cell time, and had not had any access to psychiatric care in over six months. He reported setting fires to get access to medical and mental health care. The officers' log verified Anthony's fire setting.
e. Drew E. was also housed in Division IX and admitted that he also set fires to get access after repeatedly receiving no response to his grievances over lack of access to medical and mental health care.
As demonstrated, CCJ fails to provide essential, generally accepted components of an adequate treatment programs in a correctional mental health system. The crisis level of care lacks the capacity for necessary short-term treatment. There is not adequate physical space for evaluating and treating inmates in the emergency or RCDC areas. At present, psychiatrists do not go to the general population to see inmates or conduct clinics. In addition, psychiatrists do not make rounds in any segregation areas. Rather, all inmates are brought to the emergency room area to be seen. The result is that inmates who for security reasons or lack of escort correctional staff cannot be brought to the emergency room area, are not seen.
In addition, CCJ does not have access to an acute care program that would provide appropriate access for inpatient hospitalization. For example, mental health staff have no involvement in substance abuse assessment or treatment and make no referrals for substance abuse assessment or treatment. Also, a chronic care program for inmates with serious mental illnesses does not exist. While CCJ does provide segregated housing units for inmates with serious mental illnesses, these housing units lack an adequate treatment program, which is an essential component of an adequate chronic care program.
3. Inadequate Psychotropic Medication Administration
CCJ fails to timely and appropriately evaluate inmates for the administration of psychotropic medications and to monitor

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their continued administration. Many CCJ inmates require psychotropic medications to avoid the unnecessary suffering of acute and chronic episodes of mental illness. Generally accepted correctional mental health care standards require that a physician see an inmate usually before, but clearly shortly after, a prescription for psychotropic medication is written.in order to evaluate whether the medication should be maintained and to evaluate the continued administration for proper dosage and effectiveness. Inmates who remain untreated, or who are treated without being seen by a physician, may suffer from a worsening of their symptoms, including suicidal and homicidal thoughts, or from the potentially lethal side effects of medication. CCJ consistently fails to follow this practice.
We found significant problems with regard to medication management, which include the following: (1) delays ranging from days to weeks for inmates having their psychotropic medications started after their admission to CCJ; (2) breaks in receiving their medications after their prescriptions were initiated at CCJ related to housing changes and nurse unavailability for medication administration; (3) inmates not receiving their prescribed medications due to being locked down for extended periods of time and unable to receive medications when called; (4) numerous medication errors appeared to be common; (5) psychotropic medications being prescribed or reordered without any clear medical rationale or justification; and (6) lack of monitoring for side effects, or potential toxicity, particularly with regard to the psychotropic drugs Lithium, Depakote, and Clozaril.
As confirmed by our investigation and acknowledged by the Director of Psychiatry, inmates routinely do not receive medications as prescribed or have lapses in medication administration. Medication errors were common due to nurses being overwhelmed and failing to observe inmates taking their medications or to assure that the medication was delivered as prescribed.
Medication administration problems are compounded by the fact that psychiatrists do not utilize any formal practice guidelines or protocols with regard to the psychiatric care being provided at CCJ. No routine lab work, weights, measurements, or screenings are conducted regardless of the medication being prescribed. Generally accepted professional standards require regular blood draws and lab work whenever certain psychotropic drugs are prescribed to ensure that the patient is receiving therapeutic levels of the medication. Metabolic syndrome which is characterized by the presence of risk factors including

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 66 of 99 PageID #:75
obesity, abnormal lipid profiles (high LDL cholesterol, low LDL cholesterol, and high triglycerides) is not tracked. Screening for the side effects of antipsychotic medication is not routinely done. The result is that CCJ is providing medication management that significantly departs from generally accepted professional standards. Illustrative examples from 2007 include:
a. Salazar F. did not receive his antipsychotic medication after his transfer to Division IX from CCJ's acute psychiatric unit.
b. Although Raul G. was housed in the Division V medical unit, he did not receive his prescribed antipsychotic medications for three weeks after intake.
c. Julius T. was prescribed antipsychotic, antianxiety, and antidepressant medications. The rationale for prescribing these medications could not be determined. In fact, the psychiatric portion of his medical record concerning substance abuse, depression, anxiety, and withdrawal could not be located.
d. Jones C. was prescribed three varying doses of an antipsychotic medication without clarification as to which dosage was appropriate (40mg, 60 mg, or 80 mg) or clarifying changes in dosage, if that was the case. It appeared that CCJ clinicians were engaging in polypharmacy, the inappropriate practice of prescribing multiple medications within the same class, without justification, for the same illness. He was also being prescribed two additional antipsychotic medications with no justification in the record for the multiple medication orders. It is likely that the lack of available records contributed to the disorganization of the care of this inmate.
e. Arnold R. was being prescribed an antipsychotic medication and an antidepressant without any documentation in his medical record as to the rationale for the prescription or any follow-up on his psychiatric medications.
f. Diego F. was receiving two antipsychotic medications and an antidepressant medication. His record contained no rationale for the medications and identified him as having no psychiatric problems.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 67 of 99 PageID #:76
4. Inadequate Suicide Prevention
Suicide prevention practices at CCJ are grossly inadequate. Constitutional requirements mandate the development of suicide prevention standards. These standards require (1) an appropriate policy and procedure; (2) education and training for all staff members; (3) appropriate screening to assess suicide risk; (4) appropriate housing for those identified as at risk; (5) appropriate supervision, observation, and monitoring of those inmates so identified; (6) appropriate referrals to mental health providers and facilities; (7) appropriate communication between correctional health care and correctional personnel; (8) appropriate intervention addressing procedures of how to handle a suicide in progress; and (9) appropriate notification, reporting, and review if a suicide does occur.
CCJ1s current practice of suicide prevention does not comport with generally accepted professional standards of correctional mental health care. CCJ's written policy on suicide prevention fails to ensure appropriate management of suicidal inmates and lacks major components of an adequate suicide prevention program. For example, CCJJspolicy states that 'if a patient is determined to be an imminent risk of harm to self, they will be placed in restraints following protocol." This practice of manually restraining suicidal individuals is contrary to generally accepted professional standards and, as affirmed in conversations with CCJ staff, being utilized solely due to lack of staff for continuous observation of the suicidal inmate. The result of this inappropriate policy is the unnecessary and excessive use of restraints.
An illustrative example is inmate Dallas W. who was placed in four-point leather restraints (al'l limbs) after expressing thoughts of committing suicide, despite the fact that he exhibited no aggressive or suicidal behavior. The review of restraint logs from July 2006 to June 2007 showed that in over 50 percent of the episodes, inmates were shackled with full leather restraints because of suicidal ideation and the fact that continuous observation was unavailable. This is grossly inappropriate.
In addition, the appropriate observation of suicidal inmate patients is hindered by physical limitations of the rooms in which they are being placed. Observation rooms have blind spots and windows that are set too high for routine viewing. Moreover, many of the rooms contain numerous environmental risk factors including exposed plumbing and electrical hazards.

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Contrary to generally accepted correctional practices, CCJ correctional officers and other staff have no access to cut-down tools for quick response in the event of a suicide attempt by hanging. In each of the three CCJ suicides completed in 2008, there was a delay between discovery of the inmate hanging and removal of the noose. For example, on January 1, 2008, the first correctional officer to discover inmate Grant N. hanging from his bunk attempted to lift Grant to remove the sheet from his neck, but was unable to do so. Approximately six additional minutes elapsed before paramedics were able to cut Grant down, using a key to sever the noose.
As a result of the administrative division between corrections and health care at CCJ, communication between mental health staff and correctional staff is informal and often strained. Significant communication problems between custody and mental health staff result in a fragmented, uncoordinated system. This problem is exacerbated because suicide prevention is notunder the direction and supervision of mental health staff. Inmates placed on suicide watch are being observed by correctional officers who have a myriad of other responsibilities in addition to the observation task and have limited or no familiarity with the on-going assessment of suicidal individuals. The current suicide prevention program fails to contain different levels of supervision of the inmate based on the presenting risk factors for suicide. Staff are not appropriately trained in suicide prevention. Annual training for correctional officers regarding suicide prevention is not required. Correctional officers assigned to the mental health units do not receive any additional specialized training on working with individuals with mental illness. Finally, contrary to generally accepted practice, there is no adequate clinical administrative review by mental health staff following a suicide or a suicide attempt to identify what could have been done to prevent the act. Our review of the records of two recent inmate suicides51 illustrates the significant problems:
a. On July 27, 2006, inmate Manuel M. hanged himself to death in a maximum security wing of CCJ. A correctional officer reportedly found Manuel hanging from a bed sheet at 3:20 a.m. He had been in CCJ
51 In addition to the suicides discussed above, on
March 14, 2008, an inmate was found hanging in his Division I cell. He was hospitalized in critical condition and died when he was taken off life support on March 18, 2008. On April 14, 2008, another CCJ inmate hanged himself with a bed sheet in a Division I cell, and was pronounced dead at the hospital.

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 69 of 99 PageID #:78
approximately one week on a charge of failing to register as a sex offender. His records reveal that at intake he provided a history of suicide attempts in the past, but denied current suicidal ideation. No secondary mental health evaluation was conducted. Manuel received no additional mental health assessment prior to his death in the facility.
b. On July 25, 2006, inmate Andrew K. committed suicide by hanging himself in his cell, two days after arriving at CCJ. Andrew was discovered by another inmate. His record reveals that at the time of intake, Andrew denied suicidal ideation and no secondary mental health evaluation was conducted. Andrew's documented past history included three prior psychiatric hospitalizations, including a suicide attempt by overdose. Nevertheless, Andrew received no additional mental health assessment prior to his death. No recommendations or findings were made in the mortality review, except for the comment 'May consider a two person accommodation to watch over each other."
5. Inadeuuate Staffins, Trainins, and Supervision
CCJ1s fragmented system of providing mental health care has contributed to many of the problems above. .In addition, many of the shortcomin-qs in mental health care are exacerbated by- the lack of adequate staffing, support, training, and s u p e r v i s i ~ n . ~ ~ CCJ maintains an insufficient number of appropriately trained mental health and custody staff to provide adequate mental health services.53 Moreover, delays in access to mental health care are exacerbated by an insufficient number of staff trained to identify, respond, and provide the necessary mental health treatment. Generally accepted correctional standards of care
52 Concerns were raised by the Chief Executive Officer of the IRC regarding the decreased budget for mental health services and the resulting mental health staff cuts, particularly the decrease in the number of MHSs and the replacement of existing MHSs with less qualified individuals. The severe budget cutbacks, as reflected in decreased staffing, resulted in a "breakdown in translation and execution of mental health care."
53 We observed very limited programming on the units. An interview with the Chief Psychologist verified that within the last six months due to budget cuts and the resulting staff reduction, programming on the units had been severely reduced.

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require that facilities maintain adequate staffing to provide inmates with necessary mental health care.
Shortages in key staff areas (MHS, correctional staff, nursing, medical records, and social workers) interfere with adequate access to mental services.54 As indicated, there is an inadequate number of MHSs to provide screening and supportive mental health care. This problem is compounded by the fact that recently hired MHSs lack the necessary training and experience. As indicated, correctional staff are inadequately trained to work with mental health inmates. In addition, officers are being rotated too frequently to develop familiarity with the p ~ p u l a t i o n . ~T~here are an insufficient number of nurses to provide mental health services for the designated mental health units and to run a medication administration program that comports with generally accepted professional-standards.56 In addition, there are insufficient numbers of social workers to provide for discharge planning, continuity of care, and
54 These staffing shortages were noted by the Court Monitor for Mental Health responsible for monitoring compliance with the CCJ consent decree in Harrinqton v. DeVito, No. 74-C-3290 (N.D. Ill. Oct. 19, 1978). In his 1998 and 2002 reports, the Court Monitor for Mental Health found that a shortage of adequately trained nurses, activity therapists, mental health specialists, psychiatrists and psychologists resulted in inmates "facing significant access barriers to care and adequate therapeutic programming resources." He further found that the lack of adequate numbers of medical record technicians resulted in incomplete records, included filing not being completed in a timely fashion or misfiling, and lack of availability of records during clinical assessments. Our independent evaluation identified that inadequate staffing currently results in unconstitutional mental health care deficiencies. These same staffing deficiencies were identified by the Harrinqton lawsuit and referenced in the 1998 and 2002 Court Monitor for Mental Health's reports.
55 The Court Monitor for Mental Health also noted the lack of compliance with the Harrinston Consent Decree with regard to security staffing. He found that the failure to utilize appropriately trained correctional officers on a regular basis in mental health areas was noted to have significantly impacted the treatment offered to inmates with serious mental illness.
56 This was acknowledged by the Acting Director of Nursing who indicated it is difficult to maintain adequate psychiatric nurse coverage on the psychiatric units.

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reintegration into the community. Finally, there are an inadequate number of trained health record technicians to operate an effective health record system.

1

D. INADEQUATE FIRE SAFETY

The level of fire safety at CCJ is poor. Inadequate fire safety at any correctional institute presents a grave risk of harm from smoke, fire, and the serious security concerns that arise during an emergency. These serious risks are present throughout CCJ. There are no smoke detectors in most inmate housing areas, which means staff have no way to receive warning of fire or smoke other than from the inmates who may have set the fire. Keys are not marked for rapid identification in an emergency. Staff was often not prepared to quickly unlock the doors for rapid evacuation, not knowledgeable of how the fire alarm system works, and poorly prepared for an emergency. Weekly Divisional Reports, from February 26, 2007 through June 17, 2007, show an average of 1.8 fires per week at CCJ. During our site visits, we saw evidence in numerous cells that inmates are setting fires beneath their beds in order to utilize the metal bunk as a hot plate to heat food. Multiple inmates reported that they resort to lighting fires in their cells in order to get correctional officersf attention. Considerable improvement in built-in protection and staff preparedness is necessary to meet generally accepted standards for fire safety in a correctional setting.57

One CCJ correctional officer is assigned to make monthly fire safety 'inspections" for the entire facility. These are cursory inspections to confirm that items on a standard checklist are done. The designated officer has not had training in fire safety and apparently just fills out the inspection check list with little in-depth evaluation of safety issues. Reportedly, there is a fire safety officer for each division, but these officers' only responsibility regarding fire safety is the monthly inspection of fire extinguishers. Fire safety inspections should be done by persons trained in fire safety. They should have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, fire extinguishers, and sprinklers.

57 In addition to generally accepted correctional
standards, the Illinois Office of the State Fire Marshal requires that all jails must comply with the National Fire Protection Association's Life Safetv Code ('LSC") (200).

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I

Key control is a major problem. On several occasions during

,

our on-site visits, when officers were asked to unlock doors,

I

there was confusion as to which key unlocked a specific door or

I
if the correct key was on the ring the officer carried. In many

,

cases, several keys were tried without success, and then a key on

the same ring was found that would unlock the door. The keys were not identified by touch and the visual markings were

difficult to read in low light situations. In a correctional

setting, generally accepted correctional standards require that

,

all emergency keys be identified by sight and

On October

I

5, 2007, the Sheriff's Office reported that CCJ had made

1

improvements in key control, but we have not yet verified this

information.

Divisional emergency procedures and fire plans are different between divisions with no standard format or standard procedures. For example, the Division IV instructions require that emergency keys to be color-coded red, but other divisions do not. Some instructions include floor plans, while others do not. While it is understandable that both the physical plants and levels of security differ by division and require some variation, the general format and information should be similar. This will help employees to more easily familiarize themselves with the procedures as they move positions.

Fire drills are not being done on a regular basis on each shift. Many officers reported that they had not participated in any recent fire drills and had not had training on fire safety since the academy. According to generally accepted correctional standards, monthly fire drills are required in institutional occupan~ies.~Mo~nthly drills should rotate so that they are conducted quarterly on each shift. Drills should be conducted at differing times and under differing conditions, such as using different egress routes to confirm that officers.have the necessary keys and know how to use them. Records of each drill should be maintained for at least one year.

CCJ does not have sufficient smoke detection and sprinkler systems. Smoke detection should be installed in all housing units in accordance with generally accepted correctional

I

58 See also LSC s 23.7.5.

1

59

The Municipal Code of Chicago, Fire Prevention Code

("FPC"), also requires monthly fire drills. FPC, Article XVI,

§ 1 (15-4-920) (Jan. 1999).

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standard^.^' Basement storage areas should have sprinkler
I
protection or be enclosed in fire resistive constr~ction.~~

Stairs should be enclosed so that smoke will not travel

throughout the buildings. Most of the CCJ Divisions do not

comply with these generally accepted correctional standards. For

example, Division I, which was built in 1929, has no sprinklers

I

and no smoke detection. A manual fire alarm system is installed.

The cells are open-barred in the front and back and the doors to

the stairs are open bars from the basement to the fourth floor,

which could allow smoke to spread quickly throughout the building

in the event of a fire. Only Division XI, Dorm 4 of Division 11,

and Cermak are fully protected with automatic sprinklers. Some

of the buildings have partial sprinkler protection in selected

,

areas of the basements, while others do not. Several fire/smoke

I

barrier doors were not working properly. Many of the stairwell

and fire doors throughout CCJ were wedged open, which would allow

smoke and heat to travel quickly throughout the building. In

addition, in many divisions no one is consistently checking

emergency doors and locks to ensure that they are operational.

We found that the locking mechanisms on multiple emergency exits

in housing units had been sabotaged by inmates inserting debris

into the lock, unbeknownst to staff, which prevented the doors

from opening from inside the housing unit. This is a major

safety hazard.

In many divisions, we found extra mattresses stored inappropriately in rooms without adequate fire protection. For example, in Dormitory Two of Division 11, we found several mattresses stored in the multi-purpose room on the first floor, which is not designed or protected as a storage room. A fire in these mattresses could quickly spread smoke throughout the
building and unnecessarily expose inmates to danger. at tresses
should only be stored in designated areas that are protected against fire risks. The potential risk from CCJrs flammable mattresses is clear. On January 4, 2007, two officers were injured after an inmate in Division IX set his mattress on fire. One officer suffered smoke inhalation and was admitted to the hospital. Another officer was cut on his arm during an evacuation of the housing unit.

Finally, as discussed above, the RCDC becomes very crowded in the late afternoons and evenings. There are two doors out of this area. Assuming each door has a clear width of 34 inches,

I

6o See also LSC § 23.3.4.4.

61 See also FPC s 9 (15-1'6-030)(b); LSC s 23.3.2.

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generally accepted correctional practices indicate that each door is a sufficient exit for a crowd of 135 to 170 persons.62 That means the RCDC can safely provide emergency exits for 270-340 people. The number of RCDC occupants, including newly admitted inmates, inmates returning from court, correctional officers, and medical and mental health care staff, often swells well beyond 400 persons, clearly exceeding the available egress capacity.
E. INADEQUATE SANITATION AND ENVIRONMENTAL CONDITIONS
CCJ has severe environmental health and safety problems at every level of ~ p e r a t i o n . M~o~st CCJ staff appeared well meaning with regard to environmental conditions, even when, in some instances, the staff person had never received adequate training to sufficientlv understand the task at hand. However, inadequate
staffing, inadequate training, insufficient oversight, and a -lack
of uniformity of policies and procedures across divisional lines are detrimental tb staff who want to perform at a professional level.
1. Facility Maintenance
In a facility the size and age of CCJ, it is normal and expected that maintenance and repair work would be an on-going challenge. In a correctional setting where inmates and staff are dependent on maintenance staff for their water, heat, lighting, and ventilation, it is also expected that these issues would be addressed in a timely manner in order to reduce risks of illness and injury to inmates and staff alike. That is not the case at CCJ. Work orders generated by correctional staff are transmitted to the Cook County Facilities Management Department. During our site visits, we observed hundreds of maintenance and repair needs, many of which had not been addressed for months. Upon review of work orders generated between February and July 2007, we found 2715 were uncompleted, including many that were more than four months old. With the exception of Division XI, staff uniformly complained about the lack of timely responses to work order requests. The failure to timely process work orders exacerbates the overcrowding issues at CCJ. In Division V alone, more than 100 cells (approximately ten percent of the division's
62 See, e.q., LSC § 7.3; FPC § 10 (13-160-210).
63 Although the John Howard Association found "reasonably successful" sanitation efforts in 2007 (Court Monitoring Report at 64), conditions at CCJ were far below compliance with constitutional requirements during our on-site visits.

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capacity) were closed because of maintenance issues during our July 2007 visit.
Part of the backlog regarding work orders is a result of the division between CCJ1s correctional staff and the County Facilities Management Department. Correctional staff are not permitted to undertake any facility repair work. Even a burned out lightbulb in an inmate's cell requires a Facilities Management work order and an electrician to change the bulb. This results in inmates having no lighting in their cells for multiple days in a row, which is especially dangerous when the inmates are locked inside their cells for extended periods.
Electrical hazards were prominent throughout the housing areas and neither correctional officers nor maintenance staff seemed to be concerned about them. During our July 2007 on-site visit, 34 uncompleted work orders for exposed wiring in Division XI dated as far back as February 23, 2007. We frequently observed broken switch plate and receptacle covers with exposed live wires throughout the housing units, including shower and toilet areas where floors were wet, creating a severe shock hazard. In Division VIII, a receptacle in a recreation room was pulled completely away from the wall, with no cover plate. The outlet tested live, which is a major safety hazard to inmates and
staff .
Plumbing deficiencies were also abundant. It was common to find that multiple sinks, toilets, and showers were inoperable in a single tier. It was rare to find hot water availability in a cell, and we observed many inmates locked in cells for as long as 26 hours with no access to drinking water. We saw multiple incell plumbing leaks that resulted in constant cell flooding. Many of these conditions had existed for more than a month.
Serious ventilation issues were observed in some areas. In Division VI, Unit 2-C, 21 out of 22 cells had no ventilation because metal plates had been installed behind the grate on the supply ducts, prohibiting the movement of air into the cells.64 Although the unit was designed to house 44 inmates, it was overpopulated at the time of our visit and housed more than 60 inmates, with many inmates housed three to a cell and locked in for 26-hour periods every other day. These cells are not big enough to meet generally accepted correctional standards for

64

This condition violated Illinois County Jail Standards

701.120(a)(4).

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three inmates.65 Air quality measurements indicated excessive temperature and relative humidity within the tier. The combination of high temperature and humidity, overcrowding, and lack of air movement creates an unhealthy environment that increases the risk of disease transmission. This particular tier also had exposed wiring in the dayroom; all three of the sinks in the toilet area were out of order; two of the three showers were inoperable; a water leak under the tile on both sides of the bathroom door created a falling hazard; and six burned out lights in the dayroom resulted in unacceptably low light levels.
Finally, as discussed above, conditions in the RCDC intake area are grossly inadequate for the purpose it serves and the number of inmates who are processed through the area each day. Consistent with generally accepted correctional standards, the limited toilets available should serve a dormitory of a maximum of 36 inmates, not the several hundred inmates processed through the RCDC each day. Given the lack of timely responses to plumbing problems at CCJ, it is easy to imagine the filthy environmental conditions that exist in the RCDC when the toilets become clogged.
Maintenance and sanitation are categorically inadequate throughout the facility, exposing inmates and staff to unhealthy and unsafe'environments as a result.
2. Pest Control
The three major pest problems observed during our site visits involved mice, cockroaches and drain flies. Although mice and cockroaches are nocturnal by nature and are not generally seen in daylight hours, we did observe a few of these during our visits and found evidence of their presence. Staff and inmates alike commented on the presence of mice in the facility and many
65 None of the cells at CCJ are sized to accommodate more than two inmates per cell. In fact, the American Correctional Association waived their sizing standards for portions of the facility to allow accreditation because many of the cells do not meet current standards for housing two inmates. A third inmate in these cells has to place his mattress on the floor of the cell, further reducing the unencumbered space in the cell and making it difficult for the inmates to move around in the cell. The third inmate on the floor is forced to sleep with his face at floor level where he inhales dust particles and airborne allergens that settle to the floor, increasing the risk to the inmate of contracting respiratory infections.

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inmates had towels or other types of barriers across the bottom of their celldoors to keep the mice out of their cells at night. Drain flies are small flies that are found in shower and toilet areas where they lay their eggs in gelatinous organic matter that builds up under the rim of toilets and in floor drains. These flies were noted in several of the divisions including the Cermak medical area where fly traps were being used to capture adult flies. Outbreaks of adult flies have been associated with bronchial asthma in susceptible individuals. Their presence is also a sign of inadequate housekeeping and sanitation.
Except for the food service and Cermak hospital areas, pest control is managed by CCJ staff. CCJ has only one person assigned to conduct pest control for the entire 96-acre facility. While this person is a licensed and certified pest control operator ("Pco"), one person cannot perform adequate pest control for a facility of this size and nature. Staff indicated that the PC0 works on an on-call basis to resolve acute problems. Pest control at CCJ is totally a reactive effort. The size of the facility does not allow the PC0 to do much follow up or preventive work. We found numerous mousetraps that had heavy layers of dust on them, indicating that little follow up work was done to check the traps and to replace bait as needed.
3. Sanitation Oversisht
We were informed that CCJ has a single registered sanitarian on staff. However, upon interviewing the facility's sanitarian, we learned that she was not registered by any state or national professional organization and had no formal education as a sanitarian. She has been in her current position for six years, but has never had an opportunity for any in-service training outside of the department. She also had not had any opportunities for training on the few pieces of sanitation equipment provided to her. This lack of training severely limits her ability for professional growth to learn about current environmental health practice as well as emerging environmental issues in correctional facilities such as MRSA. The CCJ sanitarian is not being supported through training and education.
CCJ's sanitarian functions as an inspector who also provides some training to staff on chemical usage. Her inspections duties cover areas such as housekeeping, lighting, plumbing, chemicals, pest control, fire extinguishers, hot water temperatures, and the like. Housekeeping inspections are done by visiting one tier per division per month. Given the facility's size, it could be six months to a year before she is able to make a return visit to a particular tier. She checks hot water temperatures by asking the

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inmates because she has no tools to measure the temperature. She checks fire drill logs and the inspection tags on the fire extinguishers to make sure documentation is completed, but she has no involvement in the actual fire drills themselves. She checks lighting by looking for burned out fixtures because she has had no training on how to use a light meter. She inspects the kitchen but has no equipment to test or measure anything with to insure that safe food conditions exist in the kitchen. Her last servsafeQ and Illinois Department of Public Health Food Service Certification training occurred in 2001 and expired in 2006. Despite all of the inspection work she does, she has no authority to effect changes in housekeeping practices, food service operations, housing conditions, pest problems, or fire safety issues. In effect, she is an inspector of documentation more than a verifier of actual conditions at CCJ.
Organizational oversight appears to be weak throughout the divisions. We constantly observed conditions that should not have existed if staff were being held accountable for conditions in the housing areas. Staff must be aware of and take action when policies are violated by inmates and unsafe conditions are seen. Staff frequently seemed to turn their back on issues such as obvious safety hazards caused by inmates tampering with electrical outlets, hanging clothes lines from damaged light fixtures in cells or in shower areas, the accumulation of large amounts of commissary items and/or food items in their cells, etc. Apparently no one is held accountable for the poor levels of housekeeping that we observed throughout the jail.
Oversight must also extend to the inmates themselves. They must be held accountable for their actions when they do not adequately clean their cells and dayrooms, when they damage CCJ property, and when they openly violate CCJ policies. Failure to enforce inmate accountability greatly increases the maintenance load on staff and creates a higher risk for staff and inmate
injuries .
4. Housekeepinq
The level of cleanliness at CCJ is very poor. In the housing and medical areas we observed accumulations of dirt, trash, mold, and mildew that had been allowed to exist for long periods of time. Cells frequently had heavy layers of dirt and dust under the bunks and around the toilet areas. Shower areas frequently had dirt, mold, and mildew on walls and ceilings. Toilet areas were extremely unsanitary.

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Mattresses are not cleaned and sanitized between uses. Hundreds of mattresses.were seen in use that were worn to the point that they were incapable of being cleaned and many covers were missing entirely. Torn and damaged mattresses allow the transfer of harmful pathogens, such as MRSA, from person to person and also serve as convenient hiding places for shanks and other contraband.
5. Food Service
The food service program at CCJ is contracted to the Aramark Corporation, which operates two kitchens, one located in the basement of Division XI and a larger, central kitchen. The kitchens operate under a Health Analysis Critical Control Point process that is approved by the Chicago Department of Health. The food service supervisors currently have servsafea and Illinois Department of Public Health Food Service Manager Certifications. They receive outside inspections once or twice a year from the Cook County Department of Public Health and are inspected on a weekly and monthly basis by jail personnel.
The Division XI kitchen prepares approximately 4500 meals per day and operates three shifts per day seven days per week. While sanitation was problematic during our June 2007 visit, the Division XI Superintendent took immediate action and conditions were vastly improved during our July 2007 visit. However, as both of the dishwashing machines in this kitchen had been out of order since March 2007, so all pots, pans, and preparatory utensils are washed by hand without adequate sanitization procedures.
The central kitchen prepares approximately 30,000 meals per day and works 200 inmates per day in four crews. Although the County selects the inmates who work in the food service area, Aramark is responsible for their training and supervision. Inmate workers reported that they receive no training prior to working in the kitchen. Aramark staff confirmed that no formal training takes place. The correctional officers who work in the kitchen are responsible only for security.
In March 2007, CCJ found that inmate workers were not utilizing gloves or hairnets, numerous sinks had clogged drains, and excessive garbage was piled on the floor. During our on-site visits, the dishwashing machines had a very heavy scale buildup from hard water deposits that tend to clog spray nozzles and limit the effectiveness and proper washing of food contact surfaces. The floor in the dishwashing area is in poor repair, causing standing water, and is not easily cleanable as required

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by food codes. The Cook County Department of Public Health cited CCJ on March 13, 2007 for this violation.
The delivery of food to the housing areas is accomplished with non-insulated carts that are loaded from the plating line and held until they are picked up by the staff who are responsible for the delivery. The kitchen supervisor estimated that some carts are held two to three hours between plating and delivery. Because these carts are not insulated or heated, food is allowed to cool to a point at which bacterial growth can occur. Additionally, food was observed being plated at unacceptable temperatures. Food codes require that hot food be held and served at 140 degrees, but we observed food being plated for delivery at 26 to 44 degrees below the required temperatures. The low plating temperatures and significant delays in food delivery greatly increase the risk of food borne disease.
IV. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect .
the constitutional rights of inmates confined at CCJ, this facility should implement, at a minimum, the following remedial measures :
A. Protection f r o m H a r m
1. Use of Force
a. Develop and maintain comprehensive and contemporary policies and procedures regarding permissible use of force.
(1) Prohibit the use of force as a response to verbal insults or inmate threats.
(2) Prohibit the 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 CCJ has attempted a hierarchy of nonphysical alternatives which are documented.
(3) Prohibit the use of force as punishment.
b. Establish effective oversight of the use of force.

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(1) Develop and implement a policy to ensure that staff adequately and promptly reports all uses of force.
(2) Ensure that management review of incident reports, use of force reports, and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical records of inmate injuries as reported by medical professionals.
(3) 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.
(4) Develop and maintain comprehensive policies, procedures, and practices for the timely and thorough investigation of alleged staff misconduct.
(5) Develop and implement policies and procedures for the effective and accurate maintenance, inventory and assignment of chemical and other security equipment.
(6) Develop and implement a process to track all incidents of use of force that at a minimum includes the following information: the inmate (s) name, housing assignment, date and type of incident, injuries (if applicable), if medical care is provided, primary and secondary staff directly involved, reviewing supervisor, external reviews and results (if applicable), remedy taken (if appropriate), and administrative sign-off.
c. Develop an effective and comprehensive training program in the appropriate use of force.
(1) Ensure that staff receive adequate competency-based training in CCJ1s use of force policies and procedures.

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(2) Ensure that staff receive adequate competency-based training in use of force and defensive tactics.
(3) Ensure that IAD management and staff receive adequate competency-based training in conducting investigations of use of force allegations.
2. Safety and Supervision
a. Ensure that correctional officer staffing and supervision levels are appropriate to adequately supervise inmates. Discontinue the practice of cross-watching.
..-,
b. Ensure that inmate work areas are adequately supervised whenever inmates are present.
c. Ensure frequent, irregularly timed, and documented security rounds by correctional officers inside each housing unit.
d. Develop and implement policies and procedures requiring all tools, utensi,ls,equipment, flammable materials, etc. are inventoried and locked down at all times.
e. Ensure that staff adequately and promptly report incidents.
f. Develop a process to track all serious incidents that captures all relevant information, including: location, any injuries, if medical care is provided, primary and secondary staff involved, reviewing supervisor, external reviews and results (if applicable), remedy taken (if appropriate), and administrative sign-off.
g. Establish a procedure to ensure that inmates do not possess or have access to contraband. Conduct regular inspections of cells and common areas of the housing units for contraband.
h. Ensure that inmates placed in lock down status are provided with appropriate due process that has been developed and implemented in policies and procedures.

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i. Increase use of overhead recording security cameras throughout the common areas of the facility.
j. Conduct regular inspections of cells and common areas of the housing units to identify and prevent rule violations by inmates.
k. Review, and revise as applicable, all security policies and Standard Operating Procedures ("SOPS") on an annual basis.
1. Review, and revise as applicable, all security .post orders regularly.
m. Revise policies, SOPS, and post orders for all armed posts to include instruction on use of deadly force and when and under what circumstances the weapon should be used.
n. To the extent possible, taking in account the different security levels and different physical layouts in the various divisions, standardize security policies, procedures, staffing reports, and post analysis reports across the divisions.
o. Provide formal training on division-specific post orders each time a correctional officer is transferred from one division to another.
p. Implement specialized training for officers assigned to special management units, which include the Special Incarceration Units, disciplinary segregation, and protective custody units. Officers assigned to these units should possess a higher level of experience and be regularly assigned to these units for stability purposes.
3. Disciplinary Process
a. Ensure that inmates are afforded due process for any disciplinary actions against them, including promptly receiving a disciplinary ticket and a fair hearing.

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b. Ensure that disciplinary hearings are conducted in a private setting.
4. Classification
a. Develop and implement policies and procedures for an objective classification system that separates inmates in housing units by classification levels.
b. .Update facility communication practices to provide officers involved in the classification process, with current information as to cell availability on each division.
c. Update the classification system to include information on each inmate's history with the Special Incarceration Unit "level system" at CCJ.
d. Provide competency-based training and access to all supervisors on the full capabilities of the CCJ classification and inmate tracking system (or any replacement system).
5. Inmate Grievance Procedure

'7

a. Develop and implement policies and procedures to

ensure inmates have access to an adequate

grievance process that ensures that grievances are

processed and legitimate grievances addressed and

remedied in a timely manner, responses are

documented and communicated to inmates, inmates

need not confront staff prior to filing grievances

about them, and inmates may file grievances

confidentially.

b. Ensure that grievance forms are available on all units and are available in Spanish.

c. Ensure that inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, referred for investigation.

6. Access to Information

a. Ensure that newly admitted inmates receive information they need to comply with facility rules and regulations, be protected from harm,

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report misconduct, access medical and mental health care, and seek redress of grievances.
b. Ensure that inmates who are not literate are afforded the opportunity t.0 have information on facility rules and services explained to them orally.
c. Ensure that information on facility rules and services is available in Spanish.
B. Medical Care
1. Intake Screening
a. Ensure that adequate intake screening and health assessments are provided. Develop and implement an appropriate medical intake screening instrument that identifies observable and non-observable medical needs, including infectious diseases, and ensure timely access to a physician when presenting symptoms require such care.
b. Ensure that acute and chronic health needs of inmates are identified in order to provide adequate medical care.
c. Ensure that medical screening information is reviewed in a timely manner by trained medical care providers.
d. Provide adequate screening and health assessments for inmates in accordance with generally accepted correctional standards of care and ensure adequate evaluation for mental illness and suicide risk.
e. Ensure that tuberculosis ("TB") screening is conducted in a timely manner.
2. Acute care
a. Provide timely medical appointments and follow-up medical treatment. Ensure that inmates receive treatment that adequately address their serious medical needs. Ensure that inmates receive acute care in a timely and appropriate manner.

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b. Provide adequate acute care for inmates with serious and life-threatening conditions.
c. Ensure that staff are adequately trained and prepared to handle emergent situations in accordance generally accepted professional standards.
3. Chronic care
a. Ensure that inmates receive thorough assessments for, and monitoring of, their chronic illness. Develop clinical practice guidelines for inmates with chronic and communicable diseases. Ensure that standard diagnostic tools are employed to administer the appropriate preventative care in a timely manner.
Adopt and implement appropriate clinical guidelines for chronic diseases such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, and policies and procedures on, inter alia, timeliness of access to medical care, continuity of medication, infection control, medicine dispensing, intoxication/detoxification, record-keeping, disease prevention, and special needs.
c. Ensure that medical staff are adequately trained to identify inmates in need of immediate or chronic care, and provide timely treatment or referrals for such inmates.
d. 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.
e. Ensure adequate follow-up treatment and medication administration concerning all inmates with chronic conditions.

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4. Treatment and Management of Communicable Disease
a. Provide adequate treatment and management of communicable diseases, including TB and Methicillin-resistant Staphylococcus aureus
( 'MRSA" ) .
b. ,Ensure that inmates with communicable diseases are appropriately screened, isolated, and treated.
c. Ensure that inmate and staff do not interfere with HVAC and negative pressure systems.
d. Develop and implement an adequate TB control plan in accordance with generally accepted correctional standards of care. Such should provide guidelines for identification, treatment, and containment to prevent transmission of TB to staff or inmates.
e. Develop and implement policies that adequately manage contagious skin infections. Develop a skin infection control plan to set expectations and provide a work plan for the prevention of transmission of skin infections, including drug-resistant infections to staff and other inmates.
f. Conduct a sufficient initial health assessment, including screening for TB and STDs, of all inmates in a timely fashion.
g. Develop and implement adequate guidelines to ensure that inmates receive appropriate wound care.
5. Access to Health Care
a. Ensure inmates have adequate access to health care.
b. Ensure that the medical request process for inmates is adequate and provides inmates with adequate access to medical care. This process should include logging, tracking, and timely responses by medical staff.
c. Develop and implement an effective system for triaging medical requests. Ensure that sick call

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requests are appropriately triaged based up the seriousness of the medical issue.
6. Follow-Up Care
a. Provide adequate care and maintain appropriate records for inmates following hospitalization. Ensure that inmates who receive specialty or hospital care are evaluated upon their return to the facility and that, at a minimum, discharge instructions are noted and appropriately provided.
7. Record Keeping
a. Ensure that medical records are adequate to assist in providing and managing the medical care needs of inmates at CCJ.
b. Ensure that medical records are complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
8. .MedicationAdministration
a. Ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted professional standards of care.
b. Ensure that administration of medication is accurate and adequately documented. Develop policies and procedures for the accurate administration of medication and maintenance of medication records. Provide a systematic review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his condition.
c. Ensure that medicine distribution is hygienic and appropriate for the needs of inmates.
9. Medical Facilities
a. Ensure that sufficient space is available to provide inmates with adequate medical care services including: intake screening, sick call,

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physical assessment, and acute, chronic, emergency, and speciality medical care (such as geriatric and pregnant inmates).
b. Ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in medical exam rooms. Ensure that hand washing stations in medical areas are fully equipped, operational, and accessible.
10. Specialty Care
a. Ensure that specialty consultations are timely and that any resulting reports are forwarded to C C J staff. Specialist recommendations should be implemented in a timely manner or, where deemed inappropriate, a C C J physician should properly document why such recommendations were implemented. Provide adequate long-term care planning for inmates with chronic illnesses.
b. Ensure that inmates are provided adequate access to specialty care in accordance with generally accepted professional'standards of care.
c. Ensure that pregnant inmates are provided adequate care in accordance with generally accepted professional standards of care.
11. Staffing, Training, and Supervision
a. Provide adequate staffing, training, and supervision of medical and correctional staff necessary to ensure adequate medical care is provided.
b. Ensure that medical staffing is adequate for inmates1 serious medical needs and that physicians adequately monitor their patients.
c. Provide adequate physician oversight and supervision of medical staff.
d. Ensure that there is an adequate number of correctional officers to escort inmates to medical units.

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12. Dental Care
a. Ensure that inmates receive adequate dental care in accordance with generally accepted professional standards of care. Such care should be provided in a timely manner.
13. Quality Assurance Review
a. Ensure that CCJ1s quality assurance system is adequate to identify and correct serious deficiencies with the medical system.
b. Ensure that CCJ1s quality assurance system is capable of assisting in managing and treating inmate medical needs. At a minimum, such a system should be reliable and capable of tracking medical related incidents.
B. Mental H e a l t h Care:
1. Timely and Appropriately Evaluate Inmates
a. Ensure CCJ properly identifies inmates with mental illness through adequate screening.
b. Ensure that inmates with potentially serious chronic mental health illness are referred for prompt mental health evaluations and examinations by a psychiatrist.
c. Provide adequate mental health assessment and treatment in accordance with generally accepted professional standards of mental health care.
d. Ensure that adequate crisis services are available to address the psychiatric emergencies of inmates.
e. Provide staffing adequate for inmates1 serious mental health needs. Provide adequate on-site psychiatry coverage. Ensure that psychiatrists see inmates in a timely manner. Ensure that psychotropic medication prescriptions are reviewed by a psychiatrist on a regular, timely basis.
f. Provide adequate screening to properly identify inmates with mental illness. Ensure that CCJ's intake evaluation process includes a mental health

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screening that is incorporated into an inmate's medical record.
g. Develop and implement an appropriate intake screening instrument that identifies mental health needs, and ensure timely access to a mental health professional when presenting symptoms require such care.
2. Assessment and Treatment
a. Ensure that treatment plans adequately address inmates1 serious mental health needs and that the plans contain interventions specifically tailored to the -inmates1diagnoses and problems. Provide therapy services where necessary for inmates with serious mental health needs. Provide adequate opportunities for inmates and staff to have confidential communications related to mental health treatment, while maintaining appropriate security precautions.
b. Ensure that mental health evaluations done as part of the disciplinary process include recommendations based on the inmate's mental health status.
c. Provide adequate on-site psychiatry coverage for inmates1 serious mental health needs. Ensure that psychiatrists see inmates in a timely manner and that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis.
d. Ensure that medications are provided to inmates in a timely manner and that they are properly monitored.
e. Provide staffing adequate for inmates with serious mental health needs. Ensure that services, such as distribution of medications, are performed by nurses or other properly trained staff.
f. Provide policies and procedures that appropriately assess inmates with mental illness.
g. Provide adequate medical documentation and general procedures as part of the mental health

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assessments that accounts for inmates' psychiatric histories.
h. Develop and implement an appropriate intake screening instrument that identifies mental health needs, and ensure timely access to the mental health professional when presenting symptoms require such care.
3. Psychotherapeutic Medication Administration
a. Ensure timely responses to orders for medication and laboratory tests, and prompt documentation thereof in inmates' charts.
b. Ensure that adequate psychotherapeutic medication administration is provided in accordance with generally accepted professional mental health care standards.
c. Ensure that changes to inmates' psychotropic medications are clinically justified. Screen inmates on psychotropic medications for movement disorders and provide treatment where appropriate.
d. Ensure that inmates receive adequate screening and evaluation for the administration of psychotropic medications in a timely manner.
4. Other Mental Health Issues
a. Ensure that administrative segregation and observation status are not used to punish inmates for symptoms of mental illness and behaviors that are, because of mental illness, beyond their control.
b. Ensure that CCJ mental health records are centralized, complete, and accurate.
c. Ensure that CCJ quality assurance system is adequate to identify and correct serious deficiencies with the mental health system.
d. Ensure that a psychiatrist or physician conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. Seclusion or restraint

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orders should include sufficient criteria for release.
e. Ensure that all staff who directly interact with inmates (including Correctional Officers) receive competency-based training,onbasic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern); recognition of signs and symptoms evidencing a response to trauma; and the appropriate use of force for inmates who suffer from mental illness.
D. Suicide Prevention Measures
1. Provide adequate treatment for inmates with selfinjurious behavior.
Develop policies and procedures to ensure appropriate management of suicidal inmates and the establishment of a suicide prevention program.
Ensure that all staff are educated and adequately trained on suicide recognition and intervention, including pre-service and annual in-service suicide prevention training.
Provide a curriculum for pre-service and annual inservice competency-based suicide prevention training that includes an array of topics so that staff are adequately trained to identify and manage suicide.
Ensure that, prior to assuming their duties and on a regular basis thereafter, all staff who work directly with inmates have demonstrated competence in identifying and managing suicide.
Ensure that CCJ suicide prevention policies include an operational description of the requirements for both pre-service and annual in-service training.
Ensure that any staff who are exempt from suicide prevention training have limited inmate contact.
Screen all inmates upon intake, including questioning to assess current and past suicide risk.

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9 . Document inmate suicide attempts at CCJ in the 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 admitted to C C J again in the future.
10. Ensure that intake staff are sufficiently experienced and qualified to identify inmates that pose a risk for suicide, and conduct appropriate follow-up evaluations by mental health professionals of new inmates within 14 days of intake.
11. Ensure that inmates on suicide precautions receive adequate mental status examinations by a mental health clinician.
12. Ensure that suicidal inmates are housed in an area that is safe for them with appropriate supervision and observation by staff.
13. Ensure that 15- and 30-minute checks of inmates under observation for risk of suicide are timely performed and appropriately documented.
14. Provide different levels of supervision of an inmate based on the presenting risk factors for suicide.
15. Ensure that detainees placed on suicide watch are assessed adequately, monitored appropriately to ensure their health and safety, and released from suicide watch as their clinical condition indicates according to professional standards of care.
16. Ensure that cut-down tools are readily available to staff in all housing units. Train staff in use of cut-down tools.
17. Ensure a component of administrative review is implemented following a suicide or a suicide attempt to identify what could have been done to prevent the suicide.
E. F i r e and L i f e Safety
1. Ensure that all facilities have adequate fire and life safety equipment which is properly maintained and inspected.

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2. Implement competency based testing for staff regarding fire/emergency procedures.
3. Develop and implement adequate policies and procedures regarding fire prevention including emergency planning and drills.
4. Ensure that emergency keys are appropriately marked, available, and consistently stored in a quickly accessible location.
5. Ensure that fire alarms are installed and maintained in all housing areas.
6. Inventory and store all flammable, toxic, and caustic materials in a well ventilated, but locked, compartment.
7. Ensure that emergency drills are conducted on a regular basis.
F. Sanitation and Environmental Conditions
1. Sanitation and Maintenance of Facilities
a. Develop and implement policies and procedures to ensure adequate cl'eaning and maintenance of the faci1it.i.ew~ith meaningful inspection processes and documentation. Such policies should include oversight and supervision, as well as establish daily cleaning requirements for toilets, showers, and housing units.
b. Ensure prompt and proper maintenance of shower, toilet, and sink units.
c. Ensure proper ventilation and airflow in all cells and housing units. ,
d. Ensure adequate lighting in all housing units and prompt replacement and repair of malfunctioning lighting fixtures.
e. Ensure adequate pest control, including sufficient staffing for routine and follow-up pest control services.

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f. Ensure that all inmates have access to needed hygiene supplies.
g. Develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials.
h. Use cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
i. Secure all sharp medical tools.
j. Destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. Inspect and replace as often as needed all frayed and cracked mattresses.
k. Develop a plan to reduce and prevent triplebunking of inmates in cells designed for two inmates.
1. When triple-bunking of inmates is unavoidable, provide a stackable bunk, moveable platform, or cot for each triple-bunked cell, so that inmates are not required to sleep with the mattress directly on the cell floor.
3. - Environmental Control
a. Ensure adequate control and observation of CCJ cells, particularly with regard to razors, fire loading materials, commissary items, and cleaning supplies.
b. Repair electrical shock hazards; develop and implement a system for maintenance and repair of electrical outlets, devices, and exposed electrical wires.

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Sanit,aryLaundry Procedures
a. Ensure that laundry delivery procedures protect inmates from exposure to contagious disease, bodily fluids, and pathogens by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
b. To limit the spread of MRSA and other infectious disease, require inmates to provide all clothing and linens for CCJ laundering and prevent inmates from washing and drying laundry outside the formal procedures.
c. To limit the spread of MRSA and other infectious disease, ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and completely dry.
d. Provide all inmates with properly cleaned and adequate bedding and clothing.
Food Service
a. Provide training for kitchen workers in the areas of food safety and food handling to reduce the risk of food contamination and food-borne illnesses.
b. Ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are properly cleaned and sanitized.
c. Ensure that foods are served and maintained at proper temperatures.

Please note that this findings letter is a public document.

I

It will be posted 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

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regarding CCJ. Assuming there is a continuing spirit of cooperation from the County, we also would be willing to send our consultants' evaluations under separate cover. These reports are not public documents. Although the consultants1 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.
We are obligated 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 facility'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, or Joan Laser, of the United States Attorney's Office, at (312) 353-1857.
Sincerely,
Grace Chung Becker Acting Assistant Attorney General
Patrick J. Fitzgerald United States Attorney Northern District of Illinois
cc: Salvador Godinez Executive Director Cook County Department of Corrections

Case: 1:10-cv-02946 Document #: 1-3 Filed: 05/13/10 Page 99 of 99 PageID #:108
Patrick T. Driscoll, Jr. Chief, Civil Actions Bureau Office of the Cook County State's Attorney
Donald J. Pechous Assistant State's Attorney Office of the Cook County State's Attorney
Peter M. Kramer, Esq. General Counsel Cook County Sheriff's Office
Daniel F. Gallagher, Esq. Querrey & Harrow Counsel for the Sheriff's Office
Paul A. O1Grady1Esq. Querrey & Harrow Counsel for the Sheriff's Office

 
 Case: 1:10-cv-02946 Document #: 11 Filed: 05/26/10 Page 1 of 1 PageID #:185
UNITED STATES DISTRICT COURT FOR THE Northern District of Illinois − CM/ECF LIVE, Ver 4.0.3
Eastern Division

United States of America v. Cook County, Illinois, et al.

Plaintiff, Defendant.

Case No.: 1:10−cv−02946 Honorable Virginia M. Kendall

NOTIFICATION OF DOCKET ENTRY

This docket entry was made by the Clerk on Wednesday, May 26, 2010:
MINUTE entry before Honorable Virginia M. Kendall:MOTION by Plaintiff United States of America for order entering agreed order [3] is stricken. Mailed notice(tsa, )

ATTENTION: This notice is being sent pursuant to Rule 77(d) of the Federal Rules of Civil Procedure or Rule 49(c) of the Federal Rules of Criminal Procedure. It was generated by CM/ECF, the automated docketing system used to maintain the civil and criminal dockets of this District. If a minute order or other document is enclosed, please refer to it for additional information.
For scheduled events, motion practices, recent opinions and other information, visit our web site at www.ilnd.uscourts.gov.

 
 Order Form (01/2005)

United States District Court, Northern District of Illinois

Name of Assigned Judge or Magistrate Judge
CASE NUMBER
CASE TITLE

Virginia M. Kendall

Sitting Judge if Other than Assigned Judge

10 C 2946

DATE

8/17/2010

United States of America vs. Cook County, Illinois et al

DOCKET ENTRY TEXT
For these reasons, the Court in its “sound discretion,” see id., denies Banks’ Motion to Intervene as untimely.

O[ For further details see text below.]

Docketing to mail notices.

STATEMENT
Plaintiff GaryHarrington(“Harrington”) and fellow class members originallyfiled, on behalf of themselves and others similarlysituated, suit against Illinois and various Cook County officials (collectively“Defendants”) pursuant to 42 U.S.C. § 1983 alleging that Defendants failed to provide necessarymental health care in the Cook CountyDepartment of Corrections. Afterseveral years of negotiation under court supervision, the parties settled the case by consent decree. See Harrington v. DeVito, 656 F.2d 264, 266 (7th Cir. 1981). The case in its current form involves the monitoring of the consent decree. Petitioner LarryM. Banks (“Banks”)now moves to intervenein casenumber 74 C 3290, which was reassigned to this Court based on relatedness on May 27, 2010 and consolidated with case number 74 C 2949. For the reasons stated below, the Court denies Banks’ Motion to Intervene as untimely.
In his motion, Banks alleges that he was found unfit to stand trial on July25, 2007 and placed in the custodyof the Department of Human Services. On October17, 2008, he was found fit to stand trial and transferred to Cook County Jail. (R. 40, pp. 1-2.) He alleges that since being placed in Cook County Jail, the psychiatrists and psychologists assigned to treat his mental condition have failed to properly treat him or give him necessary medication. (R. 40, p. 2.) Banks requests the following forms of relief: that the Court “refer the instant matter to the local U.S. Attorney’s office for a criminal investigation of the defendants and other state actors’ knowingand willful deprivation of constitutional rights,” “issue an orderof protection barring the Countyof Cook, the [Cook County Jail], and any other County actors from retaliating against Banks,” and “for contempt of court sanction against the [Cook County Jail] for their deliberate indifference to this Court’s order to conform their facilities to the constitutionally required standard so as not to deprive the detainee of his fundamental right of access to the court.” (R. 40, p.5.)
Pursuant to Federal Rule of Civil Procedure 24, “intervention may be as of right or it may be permissive.” Fed. R. Civ. P. 24; see also Heartwood v. U.S. Forest Serv., Inc., 316 F.3d 694, 700 (7th Cir. 2003). Both Rule

10C2946 United States of America vs. Cook County, Illinois et al

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STATEMENT
24(a) (intervention of right) and Rule 24(b) (permissive intervention) require that a motion to intervene be “timely.” Fed. R. Civ. P. 24. Accordingly, the requirement of timeliness applies whetherintervention is sought as a matter of right or with the court’s permission. See Sokaogon Chippewa Community v. Babbitt, 214 F.3d 941, 949 (7th Cir. 2000). “The purpose of the [timeliness] requirement is to prevent a tardyintervenorfrom derailing a lawsuit within sight of the terminal.” Id.at 949 (citations omitted). Thus, the requirement of timeliness is a flexible one and “is determined by reference to the totality of the circumstances,” leaving much to the sound discretion of the Court. See Shea v. Angulo, 19 F.3d 343, 348-49 (7th Cir. 1994); Zurich Capital Markets, Inc. v. Coglianese, 236 F.R.D. 379, 383 (N.D. Ill. 2006) (St. Eve, J.) (“Determining whether a motion for intervention is timely is ‘committed to the sound discretion of the district judge.’”) (quoting South v. Rowe, 759 F.2d 610, 612 (7th Cir. 1985)).
The Court considers four factors in evaluating timeliness: “(1) the length of time the intervenor knew or should have known of his interest in the case; (2) the prejudice caused to the original parties bythe delay; (3) the prejudiceto the intervenorif the motion is denied; [and] (4) any other unusual circumstances.” Heartwood, 316 F.3d at 701. With respect to the first factor, although an intervenormust generally“act with dispatch,” Atl. Mut. Ins. Co. v. Airlines, Inc., 24 F.3d 958, 960 (7th Cir. 1994), the test essentiallysets out a reasonableness standard: potential intervenors need to be reasonably diligent in learning of a suit that might affect their rights, and upon so learning they need to act reasonably promptly. See Heartwood, 316 F.3d at 694. Here, Banks waited to file his motion until nearly a year after he was transferred to Cook County Jail on October 17, 2008 and allegedly began to be denied proper medication and treatment; thus, he cannot be said to have “act[ed] with dispatch.” See Atl. Mut. Ins. Co., 24 F.3d at 960.
Moreover, there would be substantial prejudice to the original parties if the Court were to allow Banks to intervene at this point, because a consent decree has already been entered into and in effect for manyyears after extensive negotiation. See People Who Care v. Rockford Bd. of Educ., 68 F.3d 172, 175 (7th Cir. 1995) (“A Declaratory Judgment and Permanent Injunction was issued in 1994, and the parties have been formulatingremedial programs, and funding for these programs, literally for years. . . . Two interim orders have been proposed, adopted and implemented, a final judgment has been issued and remedial programs arealreadywell established in the schools. Thus, we agree with the district court’s conclusion that O’Brien’s considerable delay in moving to intervene would cause significant prejudice to the parties were the intervention allowed at this late date.”). With respect to the third factor, there is little prejudice to Banks in denying his motion to intervene because he is not in any way “bound by the eventuality of [the] litigation,” and may file an individual prisoner civil rights lawsuit raising the claims that he wishes to raise here. C.f. Sam Fox Pub. Co. v. United States, 366 U.S. 683, 689 (1961) (“We regard it as fullysettled that a person whose private interests coincide with the public interest in government antitrust litigation is nonetheless not bound bythe eventualityof such litigation, and hencemaynot, as of right, intervene in it.”); compare Zurich Capital Markets Inc., 236 F.R.D. at 384 (“denying Liquidator the opportunity to intervene may impair his ability to protect his interests” because he “asserts that he has a property interest in the specific funds that ZCM seeks to recover”).
The factual scenario at issue here resembles that addressed by the court in South, 759 F.2d 610, but with several important distinctions. In South, Thomas Radick (“Radick”), a prisoner, filed a motion to intervene to enforce a consent decree between Illinois and a former prison inmate in which Illinois promised certain forms of access to the law library in a particular prison. See South, 759 F.2d at 610-11. Radick alleged that Illinois had violated numerous conditions of the decree in moving the libraryinto a temporaryfacility. See id. The district court granted the prisoner’s motion to intervene, and the Seventh Circuit affirmed, holding that Radick “was an intended third-party beneficiaryof the consent decree”and that his interests were not adequatelyrepresented byexisting parties because the original prison inmate was no longer a prisoner. See id. at 612. The Court

10C2946 United States of America vs. Cook County, Illinois et al

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STATEMENT
furtherfound the motion to interveneto be timelybecause Radick had onlydelayed one month after learning about the construction delay, and Radick would be significantly prejudiced if not allowed to intervene and protect his libraryrights. See id. Unlike in that case, see id., however, here Banks not only delayed in bringing his motion to intervene but, like in People Who Care, the parties have been “formulating remedial programs . . . literallyfor years” and hencewould be prejudiced bya late intervention of an individual party. See 68 F.3d at 175. Most importantly, however, suits based on failure to provide adequate medical care are routinely brought and appropriately addressed on an individual basis. See, e.g., Estate of Gee ex rel. Beeman v. Johnson, 365 Fed.Appx. 679, 683 (7th Cir. 2010 (“Inmates have a constitutional right to receive adequate medical treatment.”); Gayton v. McCoy, 593 F.3d 610, 620 (7th Cir. 2010) (“In order to sustain a § 1983 claim for violation of Taylor’s Fourteenth Amendment due process right to adequate medical care, the plaintiff must show that: (1) Taylor had an objectively serious medical condition; (2) the defendants knew of the condition and were deliberatelyindifferent to treating her; and (3) this indifferencecaused her some injury.”). Unlike in South, where Radick’s claims were tailored to the terms of the more finite consent decree at issue, and where he would have been prejudiced substantially if not allowed to intervenebecause his interests were no longer beingrepresented bythe original prisoner who entered into the decree, see 759 F.2d at 612, hereBanks’ interests arerepresented bythe plaintiffs and he can more easily and appropriately file an individual lawsuit seeking to remedy his failure to receive proper medical care.
For these reasons, the Court in its “sound discretion,” see id., denies Banks’ Motion to Intervene as untimely.

10C2946 United States of America vs. Cook County, Illinois et al

Page 3 of 3

 
 UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION
________________

UNITED STATES OF AMERICA, Plaintiffs,
v.
COOK COUNTY, ILLINOIS, et al., Defendants.

) No. 10 C 2946 ) ) Judge Richard A. Posner ) Judge Virginia M. Kendall ) Judge Sharon Johnson Coleman ) ________________

Opinion of Three‐Judge District Court

PER CURIAM. The Sheriff of Cook County, who is the administrator of the Cook County Jail, has moved in this case for the entry of a prisoner release order, pursuant to 18 U.S.C. § 3626. Since at least 1974 the jail has been a target of litiga‐ tion claiming that conditions in the jail violate the Eighth Amendment’s cruel and unusual punishments clause (which has been held applicable to state and local government by interpretation of the due process clause of the Fourteenth Amendment) in the case of convicted criminals, or, in the case of pretrial detain‐ ees‐‐the major part of the jail’s population—the due process clause directly; but the courts “apply the same legal standards to deliberate indifference claims brought under either the Eighth or Fourteenth Amendment.” Minix v. Canarecci, 597 F.3d 824, 830–31 (7th Cir. 2010); see City of Revere v. Massachusetts General Hospital, 463 U.S. 239, 244 (1983); Bell v. Wolfish, 441 U.S. 520, 535 n. 16 (1979). Consent orders in this long‐running litigation have included prisoner release provisions premised on the belief that the jail’s chronic overcrowding was con‐ tributing to the constitutional violations.
The current phase of litigation involving conditions in the jail began in 2008, when the Department of Justice instituted the present suit, complaining of con‐ tinued unconstitutional conditions of confinement. The suit charges inadequate protection of inmates from violence by other inmates; recourse to excessive force by guards; inadequate medical care, including suicide prevention and other men‐ tal‐health care; and unacceptable conditions of sanitation. On May 26, 2010, the district court (per Judge Kendall) approved a consent decree (referred to by the parties as the “Agreed Order”) between the United States and Cook County. Be‐ cause the Agreed Order is more comprehensive as well as more up‐to‐date than

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the previous consent decrees concerning conditions at the jail, the Agreed Order will displace them. The present motion seeks to replace the release provisions in the earlier decrees. The need for such an order has been enhanced by provisions of the Agreed Order that forbid triple bunking in tiny cells and other methods by which the jail has sought to accommodate its excess population without releasing prisoners.
Section 3626 of the federal criminal code provides that “prospective relief in any civil action with respect to prison conditions shall extend no further than necessary to correct the violation of the Federal right of a particular plaintiff or plaintiffs. The court shall not grant or approve any prospective relief unless the court finds that such relief is narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means nec‐ essary to correct the violation of the Federal right. The court shall give substan‐ tial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the relief.” 18 U.S.C. § 3626(a)(1)(A). And “no court shall enter a prisoner release order unless—(i) a court has previously entered an order for less intrusive relief that has failed to remedy the deprivation of the Federal right sought to be remedied through the prisoner release order; and (ii) the defendant has had a reasonable amount of time to comply with the previous court orders. § 3626(a)(3)(A). “In any civil action in Federal court with respect to prison conditions, a prisoner release order shall be entered only by a three‐judge court,” and “only if the court finds by clear and convincing evidence that—(i) crowding is the primary cause of the violation of a Federal right; and (ii) no other relief will remedy the violation of the Federal right.” §§ 3626(a)(3)(B), (E).
On the basis of the parties’ submissions (which include extensive expert re‐ ports and statistical tables), experience gleaned from supervision of the predeces‐ sor decrees, and a hearing that this panel conducted on January 7, 2011, we con‐ clude that the criteria for the entry of a prisoner release order have been satisfied but that the order proposed by the Sheriff (and supported by the United States) requires revision in order to comply with the statute. Although there is no oppo‐ sition to the proposed order, we have an independent responsibility to satisfy ourselves that it complies with the statute. 18 U.S.C. § 3626(c)(1). For the jail and its prisoners are not the only entities that are affected by a release order; the ef‐ fect on the safety of the law‐abiding community must be considered even if no member of that community is a party—and indeed it would be difficult for such a person to establish a right to intervene. See DeShaney v. Winnebago County, 489 U.S. 189 (1989); compare 18 U.S.C. § 3626(a)(3)(f).
The absence of such opposition is, however, germane to our consideration of the issue of public safety, an express statutory concern to which we attach par‐ ticular importance. If the proposed release of prisoners created a public safety

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hazard, it would be bound to arouse opposition. Release orders directed at the Cook County Jail go back decades, and had they endangered or been thought to endanger the community they would doubtless have drawn opposition, but, so far as we are aware, they have not either. Moreover, we are insisting that the re‐ lease order be so configured as to eliminate any well‐grounded fear that it might endanger the law‐abiding community.
Another statutory criterion for the issuance of a prisoner relief order is also incontestable in this case: a long historical procession of other orders aimed at correcting unconstitutional conditions in the Cook County Jail has failed to cor‐ rect them, as the voluminous submissions by the Justice Department and others document.
We further, and crucially, find that overcrowding is a primary cause of un‐ constitutional conditions at the jail. Those conditions, which include as noted ear‐ lier resort to excessive force by guards, grossly unsanitary and unhealthy condi‐ tions, and grossly inadequate medical (including mental‐health) care, might well exist, to an extent, even if the jail were not overcrowded (hence the need for the Agreed Order). But we interpret the statute as authorizing a prisoner release or‐ der if overcrowding is a primary cause of unconstitutional violations beyond what would exist without overcrowding. Cf. Hutto v. Finney, 437 U.S. 678, 688 (1978) (“the order [a 30‐day limitation on sentences to punitive isolation] is supported by the interdependence of the conditions producing the violation. The vandal‐ ized cells and the atmosphere of violence were attributable, in part, to over‐ crowding and to deep‐seated enmities growing out of months of constant daily friction”) (emphasis added).
Suppose without overcrowding there would be half as many constitutional violations; then overcrowding would be the primary (maybe the sole) cause of the other half. The number or percentage of violations that can be attributed to overcrowding cannot be estimated, but there is evidence for example that inci‐ dents involving recourse to excessive force are more frequent on overcrowded days in the jail. Thus we are told that “the United States’ investigation of the [Cook County Jail] found that when the [jail] was overcrowded, there was a cor‐ responding increase in fights, uses of force, and weapons, exposing inmates to harm and depriving them of their constitutional rights to safe and humane con‐ ditions of confinement.” This makes sense because the larger a rowdy crowd, the likelier guards are to overreact to rowdiness out of fear. Similarly, the chronic overcrowding of the medical facilities at the jail makes it certain that many men‐ tally ill prisoners are not being treated adequately. These unacceptable condi‐ tions are actionable constitutional violations because they are consequences of deliberate decisions (as in “deliberate indifference”)—namely the decisions to incarcerate persons who by being incarcerated in Cook County Jail are subjected

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to unconstitutional conditions of confinement. County of Sacramento v. Lewis, 523 U.S. 833, 849–50 (1998); Daniels v. Williams, 474 U.S. 327, 331 (1986); Payne ex rel. Hicks v. Churchich, 161 F.3d 1030, 1040–41 (7th Cir. 1998); cf. Washington v. Davis, 426 U.S. 229 (1976).
We must consider whether the proposed prisoner release order is the least intrusive form of relief for overcrowding, in the sense of interfering with the op‐ eration of the jail as little as is consistent with rectifying constitutional violations that are not otherwise correctible. The Agreed Order requires the jail to hire addi‐ tional staff, but the jail is finding this difficult to do because of a dearth of quali‐ fied applicants, and anyway additional staff can ameliorate but cannot eliminate the unconstitutional conditions caused by overcrowding. Adding guards may not even eliminate the risk of excessive force caused by overcrowding, especially if more guards can be hired only by lowering hiring standards. And nothing short of enlarging the medical division of the jail can enable the provision of adequate medical care if the number of prisoners in that division is not re‐ duced—and the expansion of the jail is both very slow and very costly: it is probably, as we’ll see, far more costly than a prisoner release order. Because Cook County, like so much of Illinois local government and the state government as well, is operating deep in the red (its deficit is expected to be $400 million this year), considerations of cost loom large in any analysis of alternatives to a pris‐ oner release order. And such an order, as we’ll see is, very cheap if there is no danger to the public safety—and there will be no danger if the order is properly configured, as we will require that it be.
The jail is able to “lend” some of its prisoners to other correctional facilities. It has contracts with several county jails, which it pays to house Cook County prisoners; but this is awkward because the jails are at some distance from the Cook County criminal courts, and most of the prisoners are pretrial detainees who are required to be present in those courts for hearings. Distance also im‐ poses inconvenience to their lawyers, and causes possible prejudice to the de‐ fense of their clients. In any event, this offloading to the county jails is insuffi‐ cient to relieve the overcrowding of the Cook County jail.
In an oral deal with Cook County, the Illinois Department of Corrections houses, in Illinois state prisons, parole violators who are being charged with new crimes in Cook County and so, were it not for the deal, would be Cook County’s responsibility to detain. There is no written agreement, however, and given the state’s fiscal crisis the Department may at any moment decide not to accept de‐ tainees from Cook County Jail or may decide to charge a price—maybe a very high one—to accept them. The County might have to agree to pay a very high price lest its officials find themselves in contempt of court for violating the

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Agreed Order, which imposes standards that may be impossible to meet unless the current overcrowding of the jail is relieved.
A vital consideration in evaluating a proposed prisoner release order is how many prisoners will be released under it. The prison has 9,800 beds, and on aver‐ age “only” 9,400 prisoners. But the number of prisoners fluctuates from day to day. Furthermore, the prison is segmented, and the segments are not inter‐ changeable. The prisoners housed in the medical division because they have se‐ rious physical or mental ailments cannot be shifted to another division, even if the other division might have unoccupied beds—and the medical division hap‐ pens to be the most overcrowded. The women’s division is not overcrowded, but men cannot be given the unoccupied beds there. Likewise, empty beds in the di‐ vision that is reserved for the most violent criminals cannot be given to women, the mentally and physically impaired, or timid nonviolent pretrial detainees. The result of this necessary segmentation of the jail is that every division has to have some excess (more precisely, peak‐load) capacity if overcrowding is to be avoided, and this excess capacity can be created—unless and until the jail is sub‐ stantially enlarged at great cost—only by reducing the average number of pris‐ oners. Because, moreover, the jail is very old and prisoners sometimes destroy fixtures and do other damage to the jail’s interior, parts of the jail often have to be closed for repairs, further reducing the number of available beds.
At present the jail’s average occupancy rate is 91 percent (95 percent for male detainees, and, it seems, more than 100 percent in the medical division). The Sheriff argued at the hearing that a safe margin would require reducing that av‐ erage to 85 percent, which he estimates would require releasing about 1,000 pre‐ trial detainees a year. (Only pretrial detainees would be eligible for release; they are as we said the major component of the jail’s population though there are also convicted criminals serving short sentences.) We are not yet in a position to ver‐ ify the need for an 85 percent margin (which in the Sheriff’s written submission was 75 percent); it will require substantiation. We note, however, that releasing (in the rather special sense of the term discussed below) 1,000 pretrial detainees a year would increase the population of persons charged with crime, but not de‐ tained awaiting disposition of the charge, in Cook County by only 2 percent.
This is only one respect in which the proposed release order requires revi‐ sion and further substantiation. It is illustrative of a lack of specificity that pre‐ cludes us from approving it in its present form. The decree is only a page and a half in length and is extremely general in terms. The operational portions can be quoted very briefly: “[T]he Sheriff…is permitted to release individuals on their own recognizance and/or on electronic monitoring in such numbers necessary to reduce and relieve overcrowding. The process for release to electronic monitor‐ ing and/or other alternative release mechanisms may include the appointment of

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a review panel by the sheriff to determine eligibility for release…. [T]he Sher‐ iff…may [also], at his discretion, and without further notice to the Court, transfer to the custody of the [Illinois Department of Corrections] any persons housed at the [Cook County Jail] who have previously been sentenced by a court of law to the [Department of Corrections] for an unexpired sentence of confinement at the [Cook County Jail].” There is more but these are the only provisions that bear on the scope of the proposed order. They are inadequate. Apart from the failure to explain and justify the number of Cook County inmates who would be affected by the order, there is no indication of how many would be affected by the new provision for transfer to state custody—it is not even clear if this is a new deal or a statement of the existing one. There is also no indication of whether the state is willing to accept additional transfers. (A transfer of prisoners to another correc‐ tional facility is not a “release,” but is germane to release by reducing the number of prisoners who have to be released in order to reduce overcrowding: the more transfers, the fewer releases.)
We are unhappy with the reference in the proposed order to releasing pris‐ oners “on their own recognizance and/or on electronic monitoring.” Left unspeci‐ fied are which class or classes of prisoners is or are eligible and what grounds are to be used to decide whether electronic monitoring should be required, or the prisoner allowed to go free with no restrictions or surveillance of any kind. Yet at the hearing the Sheriff’s counsel assured us that only pretrial detainees would be eligible for release, and only if they were not being charged with or have a his‐ tory of violent crimes, and that all prisoners who were released would be sub‐ jected to electronic monitoring, which is actually a variant of home detention. (That is why we said that a release order that we would approve in this case would be ordering “release” only in a special sense.) The monitoring equipment makes an electronic link between the monitored person and an installation inside his home. If he leaves the home, the link is broken, which sends a warning signal to a monitoring center, which first calls the person to make sure the connection wasn’t broken accidentally and if there is no answer dispatches sheriff’s deputies to find and jail him. So far as we are informed, no pretrial detainee released from Cook County Jail on condition of being electronically monitored has violated the terms of the release.
Release on electronic monitoring of so many of the nonviolent pretrial de‐ tainees as must be released to prevent overcrowding and thus reduce the number of constitutional violations is a safe method of relieving overcrowding. It is also inexpensive; it costs roughly half as much as housing a person in Cook County Jail. It presents none of the public‐safety concerns at issue in Coleman v. Schwar‐ zenegger, 2010 WL 99000 (E.D. & N.D. Cal. Jan. 12, 2010), the decision by a three‐ judge panel, now awaiting decision on appeal to the Supreme Court (Schwar‐

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zenegger v. Plata, No. 09–1233), ordering the release of 27 percent of the entire prison population of California over the opposition of the state.
Many of the pretrial detainees in the Cook County Jail would, moreover, be bailed on their own recognizance, or on bonds small enough to be within their means to pay, were it not for the unexplained reluctance of state judges in Cook County to set affordable terms for bail; apparently these judges consider the re‐ lease of pretrial detainees to be the Sheriff’s responsibility. But whether these judges are complying with the bond clause of the Eighth Amendment is not an issue in the litigation before us, and so we must insist that the prisoner release order specify the limitations that we have just described and indicate, with such substantiation as is reasonably obtainable, how many prisoners can be expected to be released annually. The order should also make clear that only pretrial de‐ tainees are eligible for release, and then only if they are not accused of, or have a history of, violent crime; should specify the funding source for electronic moni‐ toring equipment and for the control centers; should specify response times when a center receives a warning signal; should provide assurance that adequate funds will be available for effective electronic monitoring of all prisoners re‐ leased under the order. The order should also contain a sunset clause (cf. People Who Care v. Rockford Bd. of Education, 246 F.3d 1073, 1075–76 (7th Cir. 2001))—we suggest four years—and require annual reports to the court of progress (or re‐ gress) toward reducing overcrowding; the reporting can be included in one of the monitor reports required by the Agreed Order.
To summarize, the motion for entry of the proposed release order is denied, but without prejudice, and the parties are directed to submit a revised motion consistent with the discussion in this opinion, plus evidence to support an esti‐ mate of the number of prisoners expected to be released if the revised order is approved. The revised order and any supporting materials are due 30 days from the date of this order.
SO ORDERED.
January 11, 2011.

 
 Case: 1:10-cv-02946 Document #: 68 Filed: 03/14/11 Page 1 of 2 PageID #:1108
UNITEDȱSTATESȱDISTRICTȱCOURTȱFORȱTHEȱ NORTHERNȱDISTRICTȱOFȱILLINOIS,ȱ EASTERNȱDIVISIONȱ
________________ȱ ȱ UNITEDȱSTATESȱOFȱAMERICA,ȱ ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ)ȱȱȱȱȱȱȱNo.ȱ10ȱCȱ2946ȱ ȱ ȱ Plaintiffs,ȱ ȱ ȱ ȱ ȱ ȱȱ)ȱȱ ȱ v.ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱȱȱȱȱȱȱȱȱȱ)ȱȱȱȱȱȱJudgeȱRichardȱA.ȱPosner,ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱȱȱȱȱȱȱȱȱȱ)ȱȱȱȱȱȱJudgeȱVirginiaȱM.ȱKendallȱ COOKȱCOUNTY,ȱILLINOIS,ȱetȱal.,ȱ ȱ ȱȱȱȱ)ȱȱȱȱȱȱJudgeȱSharonȱJohnsonȱColemanȱ ȱ ȱ Defendants.ȱ ȱ ȱ ȱ ȱ ȱȱȱ)ȱ
________________ȱ ȱ
OrderȱofȱThreeȬJudgeȱDistrictȱCourtȱ
ȱ ȱ PERȱ CURIAM.ȱ Inȱ ourȱ opinionȱ ofȱ Januaryȱ 11,ȱ 2011,ȱ weȱ deniedȱ Cookȱ County’sȱ motionȱ forȱ entryȱ ofȱ theȱ proposedȱ releaseȱ orderȱ withoutȱ prejudice,ȱ invitingȱ theȱ partiesȱ toȱ submitȱ aȱ revisedȱ motionȱ consistentȱ withȱ theȱ discussionȱ andȱ directivesȱ inȱ ourȱ opinion,ȱ plusȱ evidenceȱ toȱ supportȱ anȱ estimateȱ ofȱ theȱ numberȱ ofȱ prisonersȱ expectedȱtoȱbeȱreleasedȱifȱaȱrevisedȱorderȱwasȱapproved.ȱTheȱCountyȱrespondedȱ onȱ Februaryȱ 10,ȱ andȱ theȱ Unitedȱ Statesȱ indicatedȱ itsȱ agreementȱ withȱ theȱ revisedȱ proposedȱorderȱsubmittedȱwithȱtheȱresponse,ȱandȱtheȱcourtȱconductedȱaȱhearingȱ onȱtheȱresponseȱandȱproposedȱorderȱonȱMarchȱ1.ȱ ȱ Theȱrevisedȱproposedȱorderȱcompliesȱwithȱtheȱdirectivesȱinȱourȱopinionȱandȱ isȱsatisfactoryȱwithȱtheȱexceptionȱofȱoneȱprovision.ȱTheȱorderȱstatesȱthatȱtheȱSherȬ iffȱ“mayȱreleaseȱdetaineesȱinȱorderȱtoȱreduceȱtheȱpopulationȱofȱtheȱCookȱCountyȱ Jailȱtoȱ85%ȱofȱitsȱavailableȱbedȱcapacity,”ȱuponȱspecifiedȱconditions.ȱBecauseȱtheȱ triggerȱforȱreleaseȱisȱstatedȱinȱpercentageȱterms,ȱtheȱnumberȱreleasedȱdependsȱonȱ theȱ jailȱ population,ȱ whichȱ mayȱ varyȱ unpredictablyȱ and,ȱ inȱ particular,ȱ mayȱ inȬ crease,ȱandȱalsoȱonȱtheȱavailableȱbedȱcapacity,ȱwhichȱmayȱalsoȱchange—andȱmayȱ decrease.ȱ Asȱ aȱ resultȱ ofȱ theseȱ uncertainties,ȱ itȱ isȱ impossibleȱ forȱ usȱ toȱ determineȱ howȱ manyȱ prisonersȱ mayȱ actuallyȱ beȱ releasedȱ underȱ theȱ proposedȱ order.ȱ SupȬ poseȱ thatȱ theȱ jailȱ populationȱ isȱ 10,000ȱ andȱ theȱ availableȱ bedȱ capacityȱ isȱ 9,000;ȱ 85ȱ percentȱ ofȱ theȱ availableȱ bedȱ capacityȱ wouldȱ beȱ 7,650,ȱ andȱ thisȱ wouldȱ permitȱ theȱ jailȱ toȱ releaseȱ 2,350ȱ prisoners.ȱ Nowȱ supposeȱ theȱ jailȱ populationȱ risesȱ toȱ 11,000ȱ withȱnoȱincreaseȱinȱtheȱnumberȱofȱbeds;ȱthenȱtheȱjailȱcouldȱreleaseȱ3,350ȱinmates.ȱ Bothȱ numbersȱ areȱ veryȱ high,ȱ whichȱ couldȱ weȱ suspectȱ beȱ attainedȱ onlyȱ byȱ theȱ jail’sȱrelaxingȱitsȱstandardsȱforȱreleasingȱprisoners.ȱWeȱthinkȱthatȱtheȱnumberȱthatȱ theȱjailȱshouldȱbeȱallowedȱtoȱreleaseȱshouldȱbeȱcapped,ȱratherȱthanȱleftȱtoȱtheȱvaȬ

Case: 1:10-cv-02946 Document #: 68 Filed: 03/14/11 Page 2 of 2 PageID #:1109
10ȱCOȱ2946ȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ2ȱ
gariesȱofȱsizeȱofȱjailȱpopulationȱandȱbedȱcapacity,ȱatȱ1,500.ȱIfȱtheȱjailȱwantsȱtoȱreȬ leaseȱmoreȱinmatesȱitȱshouldȱbeȱrequiredȱtoȱobtainȱourȱpermission.ȱ
Weȱwouldȱlikeȱaȱprovisionȱtoȱthisȱeffectȱincludedȱinȱtheȱproposedȱorder.ȱIfȱitȱ isȱincluded,ȱweȱcanȱmoveȱspeedilyȱtoȱapproveȱtheȱproposedȱreleaseȱorderȱasȱthusȱ modified.ȱ
SOȱORDERED.ȱ ȱ
Marchȱ14,ȱ2011.ȱ

 
 Case: 1:10-cv-02946 Document #: 70 Filed: 03/29/11 Page 1 of 2 PageID #:1111

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION
________________

UNITED STATES OF AMERICA, Plaintiffs,
v.
COOK COUNTY, ILLINOIS, et al., Defendants.

) No. 10 C 2946 ) ) Judge Richard A. Posner, ) Judge Virginia M. Kendall ) Judge Sharon Johnson Coleman ) ________________

Final Order of Three‐Judge District Court

PER CURIAM. In our opinion of January 11, 2011, we denied Cook County’s motion for entry of the proposed release order without prejudice, inviting the parties to submit a revised motion consistent with the discussion and directives in our opinion, plus evidence to support an estimate of the number of prisoners expected to be released if a revised order was approved. The County responded on February 10. The United States indicated its agreement with the revised pro‐ posed order submitted with the response. The court conducted a hearing on the response and proposed order on March 1.
In our subsequent order, of March 14, we stated that the revised proposed order complied with the directives in our opinion and was satisfactory with the exception of the provision stating that the Sheriff “may release detainees in order to reduce the population of the Cook County Jail to 85% of its available bed ca‐ pacity,” upon specified conditions. Because the trigger for release was stated in percentage terms, the number that would be released would depend on the jail population, which might vary unpredictably and, in particular, might increase, and also on the available bed capacity, which might also change. As a result of these uncertainties, it would be impossible for us to determine how many pris‐ oners might actually be released under the proposed order. We concluded that the number of detainees that the jail should be allowed to release should be capped, rather than left to the vagaries of size of jail population and bed capacity, at 1,500, and that if the jail wanted to release more inmates it would be required to obtain our permission.
On March 22 the parties, including the United States, submitted a revised proposed order which states that “the Sheriff of Cook County may release on

Case: 1:10-cv-02946 Document #: 70 Filed: 03/29/11 Page 2 of 2 PageID #:1112

10 CO 2946

2

electronic monitoring up to 1,500 pretrial detainees to prevent overcrowding and thus reduce the number of potential constitutional violations stemming from overcrowding at the Cook County Jail. The Sheriff may not release at his discre‐ tion more than 1,500 pretrial detainees without further permission from this Court.” Although this revision is broadly satisfactory, there is a slight ambiguity because if read literally the phrase “may release on electronic monitoring up to 1,500 pretrial detainees” might be thought to mean release that many every year, or every day. That is not the intention but to avoid any possible misunderstand‐ ing we modify the provision to substitute for—“the Sheriff of Cook County may release on electronic monitoring up to 1,500 pretrial detainees to prevent over‐ crowding and thus reduce the number of potential constitutional violations stemming from overcrowding at the Cook County Jail. The Sheriff may not re‐ lease at his discretion more than 1,500 pretrial detainees without further permis‐ sion from this Court”—the following: “the Sheriff of Cook County may release on electronic monitoring pretrial detainees to prevent overcrowding and thus reduce the number of potential constitutional violations stemming from over‐ crowding at the Cook County Jail. No more than 1,500 pretrial detainees may be on this release status at any time without the express permission of this Court.”
As so modified, the proposed released order is approved, and issued.
SO ORDERED.
March 29, 2011.

 
 44 Case: 1:10-cv-02946 Document #: 85 Filed: 06/13/11 Page 1 of 1 PageID #:1150

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

UNITED STATES OF AMERICA,

Plaintiff, v.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants.

No.lOC2946 Judge Virginia Kendall

AGREED ORDER

This matter coming before the Court on motion of the Sheriff of Cook County for

authority to retain Patricia Hardyman, Ph.D. as a classification consultant, and the

Court being advised, IT IS HEREBY ORDERED:

By agreement of the parties, the Sheriff of Cook County is authorized to retain

Patricia Hardyman, Ph.D. of the Criminal Justice Institute, Inc. in Middletown,

Connecticut to consult with and aid the Sheriff in the tasks required to create a

classification system which will be compliant with the Agreed Order entered on

May 26, 2010.

 
 Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 1 of 60

IN THE UNITED STATES DISTRICT COURT
 FOR THE NORTHERN DISTRICT OF ILLINOIS


UNITED STATES OF AMERICA,

)


) 


PLAINTIFF,

) 


)


v.

)

)

COOK COUNTY, ILLINOIS;

)

THOMAS DART, COOK COUNTY

)

SHERIFF (in his official capacity);

)

TODD H. STROGER, COOK COUNTY

)

BOARD PRESIDENT (in his official capacity); )

COOK COUNTY BOARD OF

)

COMMISSIONERS (in their official capacity); )

)


DEFENDANTS.

) 


__________________________________________)


Civil No. 10 C 2946

AGREED ORDER
I. INTRODUCTION
1. On February 16, 2007, the Civil Rights Division of the United States Department of Justice and the United States Attorney’s Office for the Northern District of Illinois (collectively, “United States”) notified Cook County officials of their intention to investigate conditions of confinement at the Cook County Jail (“the Facility”), pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 (“CRIPA”).
2. On June 18-22, 2007 and July 23-27, 2007, the United States toured the Facility with consultants in the fields of use of force, corrections, correctional medical care, correctional mental health care, fire safety, and environmental health.
3. Throughout the course of the investigation, the United States received complete cooperation and access to all facilities and documents from the Cook County Board of Commissioners and the Cook County Sheriff’s Office.
1

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 2 of 60
4. On July 11, 2008, the United States issued a findings letter pursuant to 42 U.S.C. § 1997 that concluded that certain conditions at the Facility violate the constitutional rights of individuals confined at the Facility. The findings letter and the conclusions therein are contested by Defendants. Furthermore, by entering into this Agreed Order, Defendants to this action do not waive the right to contest the July 11, 2008 findings letter or any of the conclusions set forth therein.
5. Defendants in this action are Cook County, Illinois; the Cook County Sheriff, Thomas Dart (in his official capacity); the Cook County Board President, Todd H. Stroger (in his official capacity); the Cook County Board of Commissioners (in their official capacities); and their successors, contractors, and agents (collectively, “Defendants”). Currently, all corrections and security functions at the Facility are administered by the Cook County Department of Corrections (“CCDOC”) under the Cook County Sheriff. Health care services at the Facility are provided by Cermak Health Services of Cook County (“Cermak”), a public entity that is administered by the Cook County Health and Hospitals System Board. Maintenance responsibilities for the Facility’s physical plant are handled by the Cook County Department of Facilities Management (“DFM”). Defendants shall ensure that all Cook County agencies will take any actions necessary to comply with the provisions of this Agreed Order.
6. The United States District Court for the Northern District of Illinois (“Court”) has jurisdiction over this action pursuant to 28 U.S.C. § 1331, 28 U.S.C. § 1345, and 42 U.S.C. § 1997. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).
7. For the purposes of this lawsuit only and in order to settle this matter, Defendants consent to the entry of a finding that the conditions at the Facility necessitate the remedial measures contained in this Agreed Order. As indicated in Section VII of this Agreed Order, the parties consent to a finding that this Agreed Order complies in all respects with the provisions of the Prison Litigation Reform Act, 18 U.S.C. § 3626(a).
8. No person or entity is intended to be a third-party beneficiary of the provisions of this Agreed Order for purposes of any civil, criminal, or administrative action, and accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Agreed Order. This Agreed Order does not create and shall not be the basis of a cause of action for any non-party. This Agreed Order is not intended to impair or expand the right of any person or organization to seek relief against Defendants or their officials, employees, or agents for their conduct. This Agreed Order does not alter legal standards governing any such claims, including those standards established by Illinois law.
2


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 3 of 60
9. The purpose of this Agreed Order is to protect the constitutional rights of the inmates detained at the Facility. The terms and requirements of this Agreed Order will be interpreted to be consistent with the measures necessary to protect the constitutional rights of inmates and are not meant to expand or contract the constitutional rights of inmates at the Facility.
II. DEFINITIONS
10. “The Facility” shall refer to the Cook County Jail, located at 2700 South California Avenue, Chicago, Illinois 60608, and shall include Divisions I-VI, VIII-XI, Cermak Health Services Building, the Receiving, Classification, and Diagnostics Center (“RCDC”), the Residential Treatment Unit (“RTU”), as well as any building that is built, leased, or otherwise used, to replace or supplement the Facility.
11. “DOJ” shall refer to the United States Department of Justice, which represents the United States in this matter.
12. “Effective date” shall mean the date the Agreed Order is signed and entered by the Court.
13. “Exigent circumstances” shall mean unexpected events or unforeseen occurrences giving rise to an emergency situation that can, in the short term, be remedied only by departing from what would otherwise be required by this Agreed Order. The overpopulation of the Facility with inmates as the result of a continuing and steady rise in inmate population over time is not an “unexpected event” or “unforeseen occurrence” within the meaning of this definition.
14. “Hot-bunk,” addressed in provision 32.l(iii), means the practice of assigning more than one inmate at the Facility to a single bed, so that the two (or more) inmates assigned to that bed must sleep on the bed in shifts.
15. “Include” or “including” shall mean “include, but not be limited to” or “including, but not limited to.”
16. “Inmate” or “inmates” shall be construed broadly to refer to one or more individuals detained at, or otherwise housed, held, or confined at the Facility.
17. “Infirmary” shall mean the areas located on the second and third floors of the Cermak Building at the Facility, or any successor facility designed to replace these areas.
18. Consistent with, or in accordance with, the term “generally accepted correctional 3

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 4 of 60
standards” shall mean those industry standards accepted by a majority of correctional professionals or organizations in the relevant subject area.
19. “Licensed Correctional Medical Technician” means an individual licensed as Emergency Medical Technician by the Illinois Department of Public Health.
20. “Qualified Medical Professional” shall mean a licensed physician, licensed physician assistant, or a licensed nurse practitioner, who is currently licensed by the State of Illinois to deliver those health care services he or she has undertaken to provide.
21. “Qualified Medical Staff” shall refer to Qualified Medical Professionals and Qualified Nursing Staff.
22. “Qualified Mental Health Professional” shall refer to an individual with a minimum of masters-level education and training in psychiatry, psychology, counseling, social work or psychiatric nursing, who is currently licensed by the State of Illinois to deliver those mental health services he or she has undertaken to provide.
23. “Qualified Mental Health Staff” shall refer to individuals with a minimum of a bachelor’s degree and two years of experience providing mental health services.
24. “Qualified Nursing Staff” means registered nurses and licensed practical nurses currently licensed by the State of Illinois to deliver those health services they have undertaken to provide.
25. “Serious suicide attempt” means a suicide attempt that is considered to be either potentially life-threatening or that required medical treatment for serious harm.
26. “Special Management Units” means those housing units of the Facility designated for inmates in administrative or disciplinary segregation, in protective custody, on suicide precautions, or with mental illness.
27. “Suicide Precautions” means any level of watch, observation, or measures to prevent selfharm.
28. “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.
29. “Use of force,” means the application of physical, chemical, or mechanical measures on 4

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 5 of 60
an inmate. “Use of force” shall not include unresisted handcuffing or unresisted shackling of inmates for movement purposes.
30. Throughout this Agreed Order, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance: “Substantial Compliance” indicates that the relevant Defendant(s) has achieved compliance with most or all components of the relevant provision of the Agreed Order. “Partial Compliance” indicates that compliance has been achieved on some of the components of the relevant provision of the Agreed Order, but significant work remains. “Non-compliance” indicates that most or all of the components of the Agreed Order provision have not yet been met.
III. SUBSTANTIVE PROVISIONS
Defendants shall take any actions necessary to comply with the substantive provisions of the Agreed Order listed below. The primary responsibility of each substantive provision is assigned to CCDOC, Cermak, or the DFM, respectively. The Parties recognize that there are a number of ways to achieve constitutional minima. In determining compliance with the substantive provisions of this Agreed Order, consideration shall be given to the operational requirements of the Facility and the policies and practices employed by CCDOC, Cermak, and DFM.
A. PROTECTION FROM HARM
31. Use of Force by Staff
a. CCDOC shall maintain comprehensive and contemporary policies and procedures, in accordance with generally accepted correctional standards, surrounding the use of force and with particular emphasis regarding permissible and impermissible uses of force.
b. CCDOC shall maintain use of force policies and pre-service and in-service training programs for correctional officers and supervisors that address the following impermissible uses of force:
(1) use of force as a response to verbal insults or inmate threats where there is no immediate threat to the safety of the institution, inmates, or staff;
(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 5

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 6 of 60
staff, unless CCDOC has attempted a hierarchy of nonphysical alternatives that are documented; (3) use of force as punishment or retaliation; (4) use of force involving striking, hitting, or punching a restrained and non-combative 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, unless lethal force is justified; and (7) use of inappropriate or excessive force. c. CCDOC shall maintain a policy to ensure that staff adequately and promptly report all uses of force, in accordance with generally accepted correctional standards. d. CCDOC shall require that use of force reports: (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 instrument(s) of restraint or control, if any, and the manner in which it was used; (4) note whether an inmate disciplinary report was completed in connection with the incident that prompted the use of force; (5) describe the nature and extent of apparent and reported injuries sustained both by the inmate and staff member; (6) contain the date and time medical attention was actually provided; (7) describe, in detailed, factual terms, the type and amount of force used as well as the precise actions taken in a particular incident; and
6


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 7 of 60
(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.
e. CCDOC shall continue to require prompt review by the shift commander of all use of force reports. The shift commander’s review of use of force reports shall include review for completeness and procedural errors, as well as review of the substantive content. If the use of force report does not comply with provision 31.d. of this Agreed Order, the shift commander shall return it to the reporting officer for revision and resubmission until it is compliant. If the shift commander believes a use of force may have been inappropriate or excessive, he or she shall immediately refer the incident for investigation.
f. CCDOC shall ensure that senior management review of uses of force includes:
(1) a timely review of medical documentation of inmate injuries, if any is submitted, as provided 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;
(2) the inmate disciplinary report, if any, associated with the use of force; and
(3) the incident report, if any, associated with the use of force.
g. CCDOC shall establish criteria that trigger referral for inappropriate or excessive use of force investigations, including but not limited to, documented or known injuries that are extensive or serious; injuries involving fractures or head trauma; injuries of a suspicious nature (including black eyes, injuries to the mouth, injuries to the genitals, etc.); and injuries that require treatment at outside hospitals.
h. When CCDOC review of use of force reports, and supporting records if applicable, reveals that reports of a use of force are materially inconsistent, conflicting, or suspicious, CCDOC shall refer that use of force incident for internal investigation.
i. CCDOC shall develop and implement a system to track all incidents of use of force that, at a minimum, includes the following information:
7

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 8 of 60
(1) a tracking number; (2) the inmate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) medical care provided (if applicable); (8) staff involved; (9) reviewing supervisor; (10) external reviews and results (if applicable); (11) remedy taken (if appropriate); and (12) administrative sign-off.
j. CCDOC shall ensure that, promptly following a use of force incident, video or photographs are taken of any and all reported or apparent injuries sustained by inmates and staff. The video or photographs will be maintained and will be included in the investigation package, if applicable.
k. CCDOC shall establish an “early warning system” that will document and track correctional officers who are involved in use of force incidents and any complaints related to the inappropriate or excessive use of force, in order to alert CCDOC administration to any potential need for retraining, discipline, problematic policies, or supervision lapses. Appropriate CCDOC leadership, supervisors, and investigative staff shall have access to this information and monitor the occurrences. CCDOC senior management shall use information from the early warning system to improve quality management practices, identify patterns and trends, and take necessary corrective action both on an individual and systemic level.
l. CCDOC shall ensure that a supervisor is present during all pre-planned uses of force, such as cell extractions.
m. Where there is evidence of staff misconduct related to inappropriate or unnecessary use of force against inmates, CCDOC shall initiate personnel actions and seek disciplinary action appropriately for any correctional officer found to have:
(1) engaged in inappropriate or excessive use of force;
(2) failed to report or report accurately the use of force; 8

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 9 of 60
(3) retaliated against an inmate or other staff member for reporting an inappropriate or excessive use of force; or
(4) interfered or failed to cooperate with an internal investigation regarding use of force in a manner inconsistent with the staff member’s statutory or contractual rights.
n. Where there is evidence of staff misconduct related to inappropriate or unnecessary use of force against inmates, CCDOC shall consider, develop, and initiate systemic remedies as appropriate.
o. CCDOC shall maintain accountability policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical and other security equipment, in accordance with generally accepted correctional standards.
p. CCDOC shall continue to conduct use of force training in accordance with generally accepted correctional standards, including:
(1) CCDOC shall maintain an effective and comprehensive use of force training program.
(2) CCDOC shall continue to ensure that correctional officers receive adequate training in CCDOC’s use of force policies and procedures, including de-escalation and defensive tactics relating to use of force.
(3) CCDOC shall continue to ensure that correctional officers receive preservice and in-service training on reporting use of force and completing use of force reports.
q. CCDOC shall provide a process for inmates to report allegations of the inappropriate or excessive use of force orally to any CCDOC staff member; said staff member shall give the inmate the opportunity to reduce his or her report to writing through a grievance or complaint form without discouragement.
r. Following a use of force, when CCDOC staff transport an inmate to receive medical care by Cermak, as necessary, the CCDOC staff member shall inform the Cermak staff member that the inmate was involved in a use of force.
s. Cermak shall ensure that, when providing medical treatment or assessment to an 9


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 10 of 60
inmate following a use of force, Qualified Medical Staff document the inmate’s injuries, if any, and any medical care provided. Cermak shall provide CCDOC senior management with a brief summary documenting the initial medical encounter following a use of force, including an anatomical drawing that depicts the areas of sustained injury, if any, and information regarding any further medical care.
t. Cermak 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 or inmate-on-inmate abuse, that health care provider shall immediately:
(1) report the suspected abuse to the Executive Director of the Office of Professional Review or other appropriate CCDOC administrator; and
(2) adequately document the matter in the inmate’s medical record.
32. Safety and Supervision
a. CCDOC shall maintain security and control-related policies, procedures, and practices that will result in a reasonably safe and secure environment for all inmates and staff, in accordance with generally accepted correctional standards.
b. CCDOC shall maintain policies, procedures, and practices to ensure the adequate supervision of inmate work areas and trustees, in accordance with generally accepted correctional standards.
c. CCDOC shall ensure that security staff conduct appropriate rounds with sufficient frequency to provide inmates with reasonable safety. Rounds shall be conducted at least once every half hour, at irregular intervals, inside each housing unit. In the alternative, CCDOC may provide direct supervision of inmates by posting a correctional officer inside the day room area of a housing unit to conduct constant surveillance. More frequent rounds shall be conducted for special management inmates who require more intensive supervision for security and safety reasons. All security rounds shall be documented on forms or logs that do not contain pre­ printed rounding times. Video surveillance may be used to supplement, but must not be used to replace, rounds by correctional officers.
d. CCDOC shall ensure that security supervisors conduct daily rounds in the inmate 10


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 11 of 60
housing units, and document the results of their inspections.
e. Cook County shall increase the use of overhead video surveillance and recording cameras to provide adequate coverage throughout the common areas of the Facility, including the RCDC, all division intake areas, mental health units, special management units, inmate housing units, and in common areas of the divisions.
f. CCDOC shall maintain a procedure to prevent inmates from possessing or having access to dangerous contraband, including conducting regular inspections of cells and common areas of the housing units to identify and prevent rule violations by inmates.
g. CCDOC shall review, and revise as applicable, all General Orders (“GOs”), Standard Operating Procedures (“SOPs”), and Post Orders on an annual basis, or more frequently as needed.
h. CCDOC shall revise policies, SOPs, and post orders for all armed posts to include proper use and safe handling of weapons and provide specific instructions on use of deadly force and when and under what circumstances such force should be used, in accordance with generally accepted correctional standards.
i. CCDOC shall standardize security policies, procedures, staffing reports, and post analysis reports across the divisions, to the extent possible, taking into account the different security levels and different physical layouts in the various divisions.
j. CCDOC shall provide formal training on division-specific SOPs to correctional officers in accordance with their assignments, and shall provide further specialized training for officers assigned to Special Management Units. Cermak Hospital shall provide Specialized training for officers assigned to psychiatric units.
k. CCDOC shall maintain in working order all monitoring equipment at the Facility that is under CCDOC’s direct control, including cameras, alarms, radios (hand held), interior and exterior lighting, x-ray and other screening equipment, and walk-through metal detectors. To the extent that the maintenance of any Facility monitoring equipment is under the control of DFM, CCDOC shall promptly report any maintenance needs and DFM shall prioritize its services to ensure that all monitoring equipment is maintained in working order.
11

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 12 of 60
l. Absent exigent circumstances, CCDOC: (i) shall house each inmate assigned to a division that is celled to one permanent bed in a cell and shall not house any inmates (including those assigned to dormitory divisions) such that they are sleeping on the floor, on a mattress on the floor, or in any area not designed or redesigned as sleeping quarters; (ii) shall not house more than two inmates to a single cell (triple-bunking); and (iii) shall not hot-bunk any inmates.
m. When exigent circumstances give rise to triple-bunking, CCDOC shall provide the third inmate in the triple-bunked cell a “boat,” stackable bunk, moveable platform, or cot, so that the inmate is not required to lay down directly on the cell floor or on a mattress on the floor.
33. Security Staffing. The parties agree that correctional officer staffing and supervision levels at the Facility must be appropriate to adequately supervise inmates, to carry out the requirements of this Agreed Order, and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards. Cook County and CCDOC shall take such actions as shall ensure that correctional officer staffing and supervision at the Facility are sufficient to achieve these purposes. These actions shall include the following:
a. In the fiscal year 2010 budget, Cook County shall allocate funds sufficient to allow for 210 additional correctional officer positions at the Facility. Consistent with provision 33.c, such funding may occur on a rolling basis, as appropriate in light of the time required to hire, train, and put on duty the additional 210 new correctional officers.
b. CCDOC shall use its best efforts (through the maintenance of the written staffing plan required by provision 33.h and otherwise) to ensure that the number of correctional officer vacancies is kept to the minimum practicable number at all times, taking into account that the timing of terminations and resignations and the resulting rate of attrition may, in ordinary course, result in there being some vacancies at any given time.
c. CCDOC shall fill the 210 additional correctional officer slots provided for in provision 33.a; fill the 285 correctional officer vacancies that existed at the Facility as of July 17, 2009; and fill any correctional officer vacancies coming into existence after that date in the following manner:
i. By December 31, 2010, CCDOC shall hire, train, and put on duty at the Facility at least 448 newly qualified correctional officers (in addition to 12

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 13 of 60
those on duty as of December 31, 2009).
ii. By March 30, 2011, CCDOC shall hire, train, and put on duty at the Facility at least 174 newly qualified correctional officers (in addition to those on duty as of December 31, 2010).
d. The parties agree that for 30 months following the effective date of this Agreed Order, Cook County and CCDOC shall not be required to provide additional correctional officer staffing and supervision at the Facility beyond that which is necessary to ensure that correctional officer staffing and supervision are sufficient to achieve the purposes set out in the introductory paragraph of provision 33 and to comply with provisions 33.a-c above.
e. Within 30 months of the effective date of this Agreed Order, the CCDOC Monitor shall assess and make a recommendation on whether the correctional officer staffing and supervision levels are appropriate to adequately supervise inmates at the Facility, in accordance with generally accepted correctional standards. If the CCDOC Monitor determines that staffing is inadequate, the CCDOC Monitor will make a recommendation regarding the appropriate number of correctional officer staff. If the parties do not accept the CCDOC Monitor’s staffing recommendation, CCDOC and Cook County shall agree to an independent, comprehensive study to determine the appropriate correctional officer staffing and supervision. The parties agree that the results of this staffing study shall provide guidance as to the sufficient number of qualified correctional officers necessary to operate the Facility safely and to carry out the requirements of this Agreed Order.
f. If the staffing study requires additional correctional officers, Cook County shall allocate funds sufficient to maintain correctional officer staffing levels necessary to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards.
g. If the staffing study requires additional correctional officers, and consistent with Cook County’s allocation of funds for security staffing, CCDOC shall hire and train sufficient number of qualified correctional officers and other staff to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards, including:
(1) Investigative staffing sufficient to meet the internal investigation responsibilities outlined in this Agreed Order; 13

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(2) Correctional officer staffing sufficient to provide inmates requiring treatment with adequate access to appropriate medical and mental health care by providing timely movement of inmates to medical units, transport of inmates who have been referred for outside specialty care, and escort, if necessary, to Qualified Medical and Mental Health Staff on housing units; and
(3) Qualified staff sufficient to monitor security cameras in real time and allow for supervisory viewing and retrieving at any time.
h. CCDOC shall maintain a written staffing plan that requires sufficient staffing to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards.
i. Absent exigent circumstances, CCDOC shall maintain a practice that does not allow for scheduled, planned, or expected cross-watching (a CCDOC practice of allowing one correctional officer to simultaneously supervise two housing units from the control center of one of the units) at any time on all maximum security and Special Management Units, and during first and second shifts throughout the Facility.
j. CCDOC may permit cross-watching on third shift in housing units that are not maximum security or Special Management Units only if the Monitor does not object after consultation and review. The Monitor’s review of the appropriateness of third-shift cross-watching on a particular housing unit shall be guided by the sufficiency of sightlines between the units being cross-watched, the adequacy of video and/or audio technologies in place, and/or other factors that bear on the safety and security of inmates and staff. If the Monitor later objects to any crosswatching that is in effect because of the Monitor’s concerns that cross-watching on a particular housing unit presents an undue risk to the safety and security of inmates and staff, CCDOC shall immediately cease such cross-watching. CCDOC may renew cross-watching on that unit again if, after further consultation with and review by the Monitor, the Monitor does not object to such renewal. Although cross-watching is permitted under the limited circumstances described herein, CCDOC will work to eliminate the practice at the Facility.
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34. Incidents and Referrals
a. CCDOC shall continue to ensure that staff adequately and promptly document all reportable incidents, including inmate fights, rule violations, inmate injuries, suicides and suicide attempts, cell extractions, medical emergencies, contraband, vandalism, escapes and escape attempts, fires, and other incidents causing a disruption to standard CCDOC practice, in accordance with generally accepted correctional standards.
b. CCDOC shall continue to ensure that correctional officers receive formal preservice and in-service training on proper incident reporting policies and procedures, in accordance with generally accepted correctional standards.
c. CCDOC shall maintain a system to track all reportable incidents (as described in provision 34.a) that, at a minimum, includes the following information:
(1) incident tracking number; (2) the inmate(s) name; (3) housing assignment; (4) date; (5) type of incident; (6) injuries (if applicable); (7) medical care (if applicable); (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.
d. CCDOC shall require prompt administrative review of incident reports. Such reviews shall include a case-by-case review of individual incidents as well as a systemic review in order to identify patterns of incidents. CCDOC shall incorporate such information into quality management practices and take necessary corrective action.
e. CCDOC 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.
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f. CCDOC shall maintain policies, procedures and practices requiring investigations to resolve issues identified during review of incident reports, disciplinary hearings, or inmate grievances, and determine appropriate remedies, in accordance with generally accepted correctional standards. At a minimum, CCDOC shall require timely and appropriate investigations of all suicides, serious suicide attempts, inmate-on-inmate violence resulting in serious injury, inmate­ on-staff violence, inmate injuries requiring treatment by an outside hospital, inmate injuries of a suspicious nature (including black eyes, injuries to the mouth, injuries to the genitals, etc.), sexual misconduct between inmates, sexual misconduct involving staff, fires, escapes, escape attempts, and deaths.
g. CCDOC shall ensure that any investigation reports indicating possible criminal behavior will be referred to the appropriate law enforcement authority.
35. Investigations
Investigations at the Facility are conducted by independent departments under the Cook County Sheriff’s Office, including the Office of Professional Review, the Criminal Investigations Unit, and the Sheriff’s Police Department. The Cook County Sheriff will assume responsibility for requiring these investigatory units to comply with the relevant provisions of this Agreed Order.
a. CCDOC shall maintain comprehensive policies, procedures, and practices for the timely and thorough investigation of alleged staff misconduct, in accordance with generally accepted correctional standards.
b. Internal investigations shall be conducted by persons who do not have supervisory responsibility for the staff member(s) being investigated.
c. CCDOC shall ensure that all internal investigations will include timely, thorough, and documented interviews of all relevant staff and inmates who were involved in, or witnessed, the incident in question.
d. CCDOC shall ensure that internal investigation reports shall include all supporting evidence, including witness and participant statements, policies and procedures relevant to the incident, physical evidence, video or audio recordings, and relevant logs.
e. CCDOC shall ensure that all investigatory staff will receive pre-service and inservice training on appropriate investigations policies and procedures, the 16

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 17 of 60
investigations tracking process, investigatory interviewing techniques, and confidentiality requirements.
f. CCDOC shall provide all investigators who will be assigned to conduct investigations of use of force incidents with specialized training in investigating use of force incidents and allegations.
g. CCDOC shall ensure that the results of each internal investigation shall be documented in an investigation report. CCDOC administration shall review the investigation reports, along with the underlying documentation, and take appropriate action. CCDOC shall implement appropriate remedies based upon the results of internal investigations.
36. Inmate Disciplinary Process
a. CCDOC shall maintain policies, procedures, and practices for a formal disciplinary process, including prompt issuance of written disciplinary citations, administrative review and disciplinary reports for alleged minor rule violations, and due process for alleged major rules violations, in accordance with generally accepted correctional standards.
b. CCDOC shall ensure that inmate disciplinary hearings are conducted in a reasonably private and secure setting.
c. CCDOC shall ensure that all inmates placed in lock down status are provided with appropriate due process that has been developed and implemented in policies and procedures, in accordance with generally accepted correctional standards. In an emergency, the Executive Director of CCDOC may order a lock down of entire areas of the Facility in order to control the situation and address serious security concerns. In such circumstances, it is not necessary to provide disciplinary hearings to each inmate affected by the lock down. However, lock downs of this nature shall be limited to only the time and scope necessary to address the emergency. For the purposes of this Agreed Order, a “lock down” shall not include the routine instances in which inmates are confined to their cells, including periods of count, over night, shift change, movement, and routine contraband sweeps.
d. CCDOC shall ensure that the disciplinary board’s written record accurately reflects the testimony and discussion from the disciplinary hearing, including any recommendations from a mental health professional regarding the extent to which 17

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disciplinary charges are related to an inmate’s serious mental illness or suggestions for minimizing the deleterious effect of disciplinary measure on the mental health status of the inmate.
e. CCDOC shall alert Cermak when inmates are placed in disciplinary segregation or protective custody.
f. CCDOC shall permit a Cermak Qualified Mental Health Staff member to serve on the disciplinary board.
37. Classification
a. CCDOC shall maintain policies and procedures for an appropriate, objective classification system that separates inmates in housing units by classification levels in order to protect inmates from unreasonable risk of harm. The system shall include consideration of an inmate’s security level, severity of current charge, types of prior commitments, suicide risk, history of escape attempts, history of violence, and special needs. CCDOC shall use best efforts to anticipate periods of unusual intake volume and schedule sufficient classification staff to timely classify inmates.
b. CCDOC shall ensure that classification staff have sufficient access to current information regarding cell availability on each division.
c. CCDOC shall include information on each inmate’s assignment to the Special Incarceration Unit “level system” at the Facility in the new Jail Management System, starting with the date the new Jail Management System becomes operational.
d. CCDOC shall provide training and access to all correctional officer supervisors on the full capabilities of the new Jail Management System’s classification and inmate tracking system (or any replacement system).
e. CCDOC shall provide ongoing internal and external review and validation of the inmate classification system to ensure its reliability and objectivity.
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38. Inmate Grievance Procedure
a. CCDOC shall maintain policies and procedures to ensure inmates have access to an adequate grievance process and to ensure that grievances may be accessed and filed confidentially, without requiring the intervention of a correctional officer, in accordance with generally accepted correctional standards. These policies and procedures should be applicable and standardized across all the Facility divisions.
b. CCDOC shall ensure that the grievances receive appropriate follow-up, including informing the grievant of the outcome, providing a timely written response, and tracking implementation of resolutions.
c. CCDOC shall ensure that grievance forms are available on all units and are available in Spanish. CCDOC shall ensure that there is adequate opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access the grievance system.
d. CCDOC shall ensure that inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, are referred for investigation. A member of the management staff shall review the grievance tracking system regularly in order to identify areas of concern.
39. Access to Information
a. CCDOC shall ensure that newly admitted inmates receive information, through an inmate handbook or orientation video, regarding the following areas: facility rules and regulations; how to report misconduct; how to report sexual abuse or assault; the process for accessing medical and mental health care; emergency procedures; rules for sending and receiving mail; the visitation process; facility schedule; the disciplinary process; and how to seek redress of grievances.
b. CCDOC shall ensure that materials on facility rules and services are available for non-literate and non-English speaking inmates.
40. CCDOC shall provide training and supervision to all correctional officers and supervisors sufficient to implement the provisions of this Agreed Order.
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B. HEALTH CARE SERVICES: ELEMENTS COMMON TO MEDICAL AND MENTAL HEALTH
41. Inter-Agency Agreement
a. CCDOC shall enter into a written Inter-Agency Agreement with Cermak that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
b. Cermak shall enter into a written Inter-Agency Agreement with CCDOC that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
42. Cermak shall provide adequate services to address the serious medical and mental health needs of all inmates, in accordance with generally accepted professional standards. The term “generally accepted professional standards” means those industry standards accepted by a majority of professionals in the relevant field, and reflected in the standards of care such as those published by the National Commission on Correctional Health Care (“NCCHC”).
a. Cermak shall develop and implement medical care policies, procedures, and practices to address and guide all medical care and services at the Facility, 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) sick call triage and physician review; (9) intake screening; (10) chronic disease management; (11) comprehensive health assessments; (12) mental health; (13) women’s health; (14) quality management;
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(15) emergent response; (16) infirmary care; (17) placement in medical housing units; (18) handling of grievances relating to health care; (19) mortality review; and (20) care for patients returning from off-site referrals.
b. Cermak shall develop and implement policies, procedures, and practices to ensure timely responses to clinician orders including, but not limited to, orders for medications and laboratory tests. Such policies, procedures, and practices shall be periodically evaluated to ensure timely implementation of clinician orders.
43. Medical Facilities
a. CCDOC will work with Cermak to provide sufficient clinical space, as identified by Cermak staff, to provide inmates with adequate health care to meet the treatment needs of detainees, including:
(1) intake screening; (2) sick call; (3) medical and mental health assessment; (4) acute, chronic, emergency, and specialty medical care (such as geriatric
and pregnant inmates); and (5) acute, chronic, and emergency mental health care.
b. Cermak staff shall make known to CCDOC and Cook County its needs for sufficient clinical space, with access to appropriate utility and communications capabilities, to provide inmates with adequate health care to meet the treatment needs of detainees, including:
(1) intake screening; (2) sick call; (3) medical and mental health assessment; (4) acute, chronic, emergency, and specialty medical care (such as geriatric
and pregnant inmates); and (5) acute, chronic, and emergency mental health care.
c. Cook County shall build out, remodel, or renovate clinical space as needed to provide inmates with adequate health care to meet the treatment needs of detainees, as identified by Cermak staff, including: 21

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 22 of 60
(1) intake screening; (2) sick call; (3) medical and mental health assessment; (4) acute, chronic, emergency, and specialty medical care (such as geriatric
and pregnant inmates); and (5) acute, chronic, and emergency mental health care.
d. Cermak shall ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in medical exam rooms. Cermak shall ensure that hand washing stations in medical areas are fully equipped, operational, and accessible.
e. Cermak shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and sharp medical tools) and hazardous waste.
f. CCDOC shall allow operationally for inmates’ reasonable privacy in medical and mental health care, and shall respect the confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically includes sight and hearing privacy from other inmates and hearing privacy from staff that are not providing health care.
g. Cermak shall make known to CCDOC and Cook County the structural and operational requirements for inmates’ reasonable privacy in medical and mental health care. Cermak shall provide operationally for inmates’ reasonable privacy in medical and mental health care and shall maintain confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically includes sight and hearing privacy from other inmates and hearing privacy from staff that are not providing health care.
h. Cook County shall build out, remodel, or renovate clinical space as needed to allow structurally for inmates’ reasonable privacy in medical and mental health care, as identified by Cermak and CCDOC staff.
i. Cook County shall begin construction of the new clinical space within three months of the effective date of this Agreed Order. It is expected that the project will be complete within nine months of the effective date of this Agreed Order. Prior to completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding clinical space, to the 22


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extent possible in the current Facility.
44. Staffing, Training, Supervision, and Leadership
a. Cermak shall maintain a stable leadership team that clearly understands and is prepared to move forward toward implementation of the provisions of this Agreed Order, with respect to:
(1) Medical care; and (2) Mental health care.
b. Cermak shall maintain an adequate written staffing plan and sufficient staffing levels of health care staff to provide care for inmates’ serious health needs, including:
(1) Qualified Medical Staff; and (2) Qualified Mental Health Staff.
c. Cermak shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious health care needs of inmates. All such staff shall receive documented orientation and in-service training on relevant topics, including:
(1) Provision of health care in a correctional setting and Facility-specific issues; and
(2) Suicide prevention, and identification and care of inmates with mental illness.
d. Cermak shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.
e. Cermak shall ensure that all persons providing health care meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, Cermak shall verify that all health care staff have current, valid, and unrestricted professional licenses and/or certifications for:
(1) Medical staff; and (2) Mental health staff.
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f. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on recognition and timely referral of inmates with medical urgencies, including drug and alcohol withdrawal. Cermak will provide adequate initial and periodic training on these topics to all Cermak staff who work with inmates.
g. CCDOC will provide, to all CCDOC staff who work with inmates, adequate initial and periodic training on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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.
h. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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.
g. Cermak shall ensure that all health care staff receive adequate training to properly implement the provisions of this Agreed Order, including:
(1) Medical staff; and (2) Mental health staff.
45. Intake Screening
a. Cermak shall maintain policies and procedures to ensure that adequate medical and mental health intake screenings are provided to all inmates.
b. Cermak shall ensure that, upon admission to the Facility, Qualified Medical Staff or Licensed Correctional Medical Technicians utilize an appropriate medical intake screening instrument to identify and record observable and non-observable 24

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medical needs, shall assess and document the inmate’s vital signs, and shall seek the inmate’s cooperation to provide information, regarding:
(1) medical, surgical, and mental health history, including current or recent medications, including psychotropic medications;
(2) history and symptoms of chronic disease, including current blood sugar level for inmates reporting a history of diabetes;
(3) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use;
(4) history of substance abuse and treatment; (5) pregnancy; (6) history and symptoms of communicable disease; (7) suicide risk history; and (8) history of mental illness and treatment, including medication and
hospitalization.
c. Cermak shall ensure that, upon admission to the Facility, Qualified Mental Health Staff, Qualified Medical Staff, or Licensed Correctional Medical Technicians utilize an appropriate mental health intake screening instrument to identify and record observable and non-observable mental health needs, and seek the inmate’s cooperation to provide information, 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) previously identified suicide risk during any prior confinement at
CCDOC; (6) any observations of the transporting officer, court, transferring agency, or
similar individuals regarding the inmate’s potential suicide risk, if such information is communicated to Cermak staff; (8) psychotropic medication history; and (9) alcohol and other substance use and withdrawal history.
d. Cermak shall ensure that all Qualified Mental Health Staff, Qualified Medical Staff, or Licensed Correctional Medical Technicians who conduct the medical and mental health intake screenings are properly trained on the intake screening process, instrument, and the requirements and procedures for referring all qualifying inmates for further assessment.
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e. If Cermak assigns Licensed Correctional Medical Technicians to perform intake screening, they shall receive appropriate, on-site supervision by on-site Qualified Medical Staff; information obtained on screening for all inmates will be reviewed by Qualified Medical Staff before the inmate departs the intake area.
f. Cermak shall ensure that a medical assessment based on the symptoms or problems identified during intake screening is performed within two working days of booking at the Facility, or sooner if clinically indicated, by a Qualified Medical Professional for any inmate who screens positively for any of the following conditions during the medical or mental health intake screenings:
(1) Past history and symptoms of any chronic disease included on a list specified by Cermak’s policies and procedures;
(2) Current or recent prescription medications and dosage, including psychotropic medications;
(3) Current injuries or evidence of trauma; (4) Significantly abnormal vital signs, as defined by Cermak’s policies and
procedures; (5) Risk of withdrawal from alcohol, opioid, benzodiazepine, or other
substances; (6) Pregnancy; (7) Symptoms of communicable disease; and (8) History of mental illness or treatment, including medication and/or
hospitalization.
g. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake process receives a comprehensive mental health evaluation (see provision 59.c, “Mental Health: Assessment and Treatment”) Cermak shall ensure timely access to a Qualified Mental Health Professional for this purpose, based on emergent, urgent, and routine medical or mental health needs.
h. Cermak shall ensure that the intake health screening information is incorporated into the inmate’s medical record in a timely manner.
i. Cermak shall implement a medication continuity system so that incoming inmates’ medication for serious medical and mental needs can be obtained in a timely manner, as medically appropriate. Within 24 hours of an inmate’s booking at the Facility, or sooner if medically necessary, a Qualified Medical Professional 26


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 27 of 60
or Qualified Mental Health Professional, with appropriate prescribing authority, shall decide whether to continue the same or comparable medication for serious medical and mental health needs that an inmate reports during intake screening that she or he has been prescribed. If the inmate’s reported medication is discontinued or changed, other than minor dosage adjustments or substitution of a therapeutic equivalent, a Qualified Medical Professional or Qualified Mental Health Professional, with appropriate prescribing authority, shall evaluate the inmate face-to-face as soon as medically appropriate, and within no greater than five working days, and document the reason for the change.
46. Emergency Care
a. Cermak shall train health care staff to recognize and respond appropriately to health care emergencies, including:
(1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
b. CCDOC shall train correctional officers to recognize and respond appropriately to health care emergencies, including:
(1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
c. CCDOC shall ensure that all inmates with emergency health care needs receive prompt transport, including transport for outside care, for emergencies including:
(1) Medical emergencies; and (2) Mental health emergencies.
d. Cermak shall ensure that all inmates with emergency health care needs receive timely and appropriate care, with prompt referrals for outside care when medically necessary, and shall notify CCDOC when emergency transport is needed inside or outside the Facility compound, for emergencies including:
(1) Medical emergencies; and (2) Mental health emergencies.
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Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 28 of 60
e. CCDOC shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation (“CPR”) and addressing serious bleeding) in emergency situations. CCDOC shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
47. Record Keeping
a. Cermak 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 the Facility and are maintained consistent with local, federal, and state medical records requirements.
b. Cermak 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.
c. To ensure continuity of care, Cermak shall submit appropriate medical information to outside medical providers when inmates are sent out of the Facility for medical care. Cermak shall appropriately request 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.
d. Cermak shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
48. Mortality Reviews
a. Cermak shall request an autopsy, and related medical data, for every inmate who dies while in the custody of CCDOC, including inmates who die following transfer to a hospital or emergency room.
b. Relevant CCDOC personnel shall participate in Cermak’s mortality review for each inmate death while in custody, including inmates who die following transfer to a hospital or emergency room, 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 seek to determine whether there was a systemic or specific problem that may have contributed to the incident. At a minimum, CCDOC’s contribution to mortality and morbidity reviews shall 28

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include:
(1) critical review and analysis of the correctional circumstances surrounding the incident;
(2) critical review of the correctional procedures relevant to the incident; (3) synopsis of all relevant training received by involved correctional staff; (4) possible precipitating correctional factors leading to the incident; and (5) recommendations, if any, for changes in correctional policy, training,
physical plant, and operational procedures.
c. Cermak shall conduct a mortality review for each inmate death while in custody, including inmates who die following transfer to a hospital or emergency room, and a morbidity review for all serious suicide attempts or other incidents in which an inmate was at high risk for death. Cermak shall engage relevant CCDOC personnel in mortality and morbidity reviews 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.
d. Cermak shall address any problems identified during mortality and morbidity reviews through timely training, policy revision, and any other appropriate measures.
49. Cermak shall develop and implement policies and procedures for appropriate handling of grievances relating to health care, when such grievances are forwarded from CCDOC.
C. MEDICAL CARE
50. Health Assessments
a. Cermak shall ensure that Qualified Medical Professionals attempt to elicit the 29

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amount, frequency and time since the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication.
b. Cermak shall ensure that incoming inmates who present and are identified by medical personnel as having either a 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 or Qualified Mental Health Staff with appropriate, on-site supervision 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.
c. Cermak shall ensure that all inmates at risk for, or demonstrating signs and symptoms of, drug and alcohol withdrawal are timely identified. Cermak shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.
d. CCDOC shall maintain a policy 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.
e. Cermak shall ensure that the medical assessment performed within two working days of his or her booking at the Facility, or sooner if clinically indicated, for each inmate specified above (provision 45.f, “Intake Screening”) shall include a review of the inmate’s intake screening form, a medical history, a physical examination, a mental health history, and a current mental status examination. The physical examination shall be conducted by a Qualified Medical Professional. The medical assessment shall also include development or revision of the inmate’s problem list and treatment plan to address issues identified during the medical assessment. 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 medical assessment within the previous six months and whose receiving screening shows no change in the inmate’s health status need not receive a new medical assessment. For such inmates, Qualified Medical Staff shall review prior records and update tests and examinations as needed.
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51. Acute care
a. Cermak 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.
b. Cermak shall maintain guidelines for the scope of care of acutely ill patients in its on-site designated infirmary units and for transfer of patients when appropriate to outside hospitals.
52. Chronic care
a. Cermak shall maintain an appropriate, written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring, and continuity of care consistent with the inmates’ expected length of stay.
b. Cermak shall maintain appropriate written clinical practice guidelines for chronic diseases, such as HIV, hypertension, diabetes, asthma, and elevated blood lipids.
c. Cermak shall maintain an updated registry to track all inmates with serious and/or chronic illnesses and shall monitor this registry to ensure that these inmates receive necessary diagnoses and treatment. Cermak shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates’ individual medical records.
d. Cermak shall ensure that inmates with chronic conditions are routinely seen by a physician, physician assistant, or advanced practice nurse to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions.
e. CCDOC shall house inmates with disabilities, or who need skilled nursing services or assistance with activities of daily living, in appropriate facilities, as determined by Cermak. CCDOC shall permit inmates with disabilities to retain appropriate aids to impairment, as determined by Cermak.
f. Cermak shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically 31

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 32 of 60
appropriate care. Cermak shall notify CCDOC of their specific needs for housing and aids to impairment.
g. Cook County shall build out, remodel, or renovate clinical space as needed to provide appropriate facilities for inmates with disabilities in accordance with the timelines set out in provision 43.i. Prior to completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding facilities for inmates with disabilities, to the extent possible in the current Facility.
53. Treatment and Management of Communicable Disease
a. Cermak shall maintain adequate testing, monitoring, and treatment programs for management of communicable diseases, including tuberculosis (“TB”), skin infections, and sexually transmitted infections (“STIs”).
b. CCDOC shall comply with infection control policies and procedures, as developed by Cermak, that address contact, blood borne, and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs, consistent with generally accepted correctional standards of care.
c. Cermak shall maintain 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, consistent with generally accepted correctional standards of care. Such policies should provide guidelines for identification, treatment, and containment to prevent transmission of infectious diseases to staff or inmates.
d. Pursuant to Centers for Disease Control (“CDC”) Guidelines, Cermak shall continue to test all inmates for TB upon booking at the Facility and shall follow up on test results as medically indicated. Cermak shall follow current CDC guidelines for management of inmates with TB infection, including providing prophylactic medication when medically appropriate and consistent with the inmate’s expected length of stay. Inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB, and housed in an appropriate, specialized respiratory isolation (“negative pressure”) room. Cermak shall notify CCDOC of inmates’ specific housing requirements and precautions for transportation for the purpose of infection control. 32

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 33 of 60
e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing.
f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting, and ventilation problems.
g. Cermak 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.
h. Cermak shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases.
54. Access to Health Care
a. CCDOC will work with Cermak to facilitate timely and adequate accessibility of appropriate health care for inmates, as provided by Cermak.
b. Cermak shall ensure the timely and adequate availability of appropriate health care for inmates.
c. Cermak 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) opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and
(3) opportunity for all inmates, irrespective of primary language, to access medical and mental health care.
d. Cermak shall ensure that the sick call process includes confidential collection, 33

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 34 of 60
logging, and tracking of sick call requests seven days a week. Cermak shall ensure timely responses to sick call requests 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. Cermak shall document the reason for and disposition of the medical or mental health care request in the inmate’s medical record.
e. Cermak shall develop and implement an effective system for screening medical requests within 24 hours of submission. Cermak shall ensure that sick call requests are appropriately prioritized based upon the seriousness of the medical issue.
f. Cermak shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting.
g. Cermak 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.
55. Follow-Up Care
a. Cermak shall provide adequate care and maintain appropriate records for inmates who return to the Facility following hospitalization or outside emergency room visits.
b. Cermak shall ensure that inmates who receive specialty, emergency room, or hospital care are evaluated upon their return to the Facility 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.
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56. Medication Administration
a. Cermak shall ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted correctional standards of care.
b. Cermak shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. Cermak 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. Cermak shall ensure that medicine administration is hygienic, appropriate for the needs of inmates, and is recorded concurrently with distribution.
d. Cermak shall ensure that medication administration is performed by Qualified Nursing Staff.
e. When Cermak prescribes medication to address an inmate’s serious mental health needs, HIV or AIDS, or thromboembolic disease, Cermak shall alert CCDOC that the inmate in question is on a flagged medication. If the prescription is terminated during an inmate’s stay at the Facility, Cermak will notify CCDOC.
f. When CCDOC receives notice that an inmate is on a flagged medication, CCDOC shall include notation of a medication flag in the inmate’s profile on the Facility’s Jail Management System.
g. When an inmate with a medication flag is processed for discharge at the Facility, CCDOC shall escort the inmate to designated Cermak staff in the intake screening area of the Facility for discharge medication instructions.
h. When CCDOC escorts an inmate with a medication flag to Cermak staff during discharge processing, Cermak staff shall provide the inmate with printed instructions regarding prescription medication and community resources.
i. Each morning, CCDOC shall provide Cermak with a list of all inmates with medication flags who were discharged the previous day.
j. Within 24 hours of discharge of an inmate with a medication flag, Cermak shall call in an appropriate prescription to the designated pharmacy on the Stroger 35

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Hospital campus to serve as a bridge until inmates can arrange for continuity of care in the community.
k. CCDOC shall ensure that information about pending transfers of inmates is communicated to Cermak as soon as it is available.
l. When CCDOC has advance notice and alerts Cermak of the pending transfer to another correctional facility of inmates with serious medical or mental health needs from detention, Cermak shall supply sufficient medication for the period of transit. In such cases, Cermak shall prepare and send with transferring inmates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Facility.
m. CCDOC shall ensure that the transfer summary and any other medical records provided by Cermak will accompany inmates, or will be made available electronically or transmitted by facsimile, when they are transferred from the Facility to another institution.
57. Specialty Care
a. Cermak shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at the Facility shall receive timely and appropriate referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
b. Upon reasonable notification by Cermak, CCDOC will transport inmates who have been referred for outside specialty care to their appointments.
c. Cermak 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. Cermak shall provide reasonable notice to CCDOC of such appointments so that CCDOC can arrange transportation. Inmates awaiting outside care shall be seen by Qualified Medical Staff as medically necessary, at clinically appropriate intervals, to evaluate the current urgency of the problem and respond as medically appropriate. If an inmate refuses treatment following transport for a scheduled appointment, Cermak shall have the inmate document his refusal in writing and include such documentation in the inmate’s medical record.
d. Cermak shall maintain a current log of all inmates who have been referred for 36

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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.
e. Cermak shall ensure that pregnant inmates are provided adequate pre-natal care. Cermak 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.
58. Dental Care
a. Cermak shall ensure that inmates receive adequate dental care, and follow up, in accordance with generally accepted correctional standards of care. Such care should be provided in a timely manner, taking into consideration the acuity of the problem and the inmate’s anticipated length of stay. Dental care shall not be limited to extractions.
b. Cermak shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
D. MENTAL HEALTH CARE
59. Assessment and Treatment
a. Results of mental health intake screenings (see provision 45.c, “Intake Screening”) will be reviewed by Qualified Mental Health Staff for appropriate disposition.
b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates’ mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs.
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental 37

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 38 of 60
Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate’s medical record.
d. Cermak shall ensure clinically appropriate and timely treatment for inmates whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
e. Cermak shall ensure that treatment plans adequately address inmates’ serious mental health needs and that the plans contain interventions specifically tailored to the inmates’ diagnoses.
f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates’ serious mental health needs and ensure that psychiatrists see inmates in a timely manner.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defining the various levels of care and identifying the space, staffing, and programming that are appropriate to each identified level of care.
h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate.
i. Cermak shall provide the designated CCDOC official responsible for inmate disciplinary hearings with a mental health caseload roster listing the inmates 38

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 39 of 60
currently receiving mental health care.
j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate’s serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate’s mental health status.
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak’s assessment.
l. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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
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for inmates on psychotropic medications. In addition, inmate’s medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year.
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate’s psychotropic medications are clinically justified and documented in the inmate’s medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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.
E. SUICIDE PREVENTION MEASURES
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and 40

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monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

c. 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.

62. Suicide Precautions

a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.

b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.

c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.

d. Cermak shall develop and implement policies and procedures for suicide 41

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precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.

63. Cermak shall ensure that Qualified Mental Health Staff assess and interact with (not just observe) inmates on Suicide Precautions, and document the assessment and interaction on a daily basis.

64. Suicide Risk Assessments

a. Cermak 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.

b. Cermak shall ensure that the risk assessment shall include the following:

(1)

description of the antecedent events and precipitating factors;

(2)

mental status examination;

(3)

previous psychiatric and suicide risk history;

(4)

level of lethality;

(5)

current medication and diagnosis; and

(6)

recommendations or treatment plan. Findings from the risk

assessment shall be documented on both the assessment form and in

the inmate’s medical record.

65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.

66. Suicide Prevention Policies

a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
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b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
67. DFM shall ensure that cells designated by CCDOC or Cermak for housing suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars.
68. Suicide Prevention Training a. Cermak shall ensure that the Facility’s suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools.
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b. Within 24 months of the effective date of this Agreed Order, CCDOC shall train all CCDOC staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. 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 in accordance with generally accepted professional standards.
c. Within 12 months of the effective date of this Agreed Order, Cermak shall train all Cermak staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. 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 in accordance with generally accepted professional standards.
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily available, safely secured, suicide cut-down tools.
70. Cermak shall document inmate suicide attempts at the Facility, as defined by the Suicide Prevention Committee’s policies and procedure in accordance with generally accepted correctional standards, in the inmate’s correctional record in CCDOC’s new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.
F. FIRE AND LIFE SAFETY
71. CCDOC and DFM shall work together to develop and implement a comprehensive fire safety program and ensure compliance is appropriately documented. The initial fire safety plan shall be approved by the fire prevention authority having jurisdiction. The fire safety plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and emergency procedures shall be standardized across divisions, to the extent possible given differences in physical plant and security levels.
72. CCDOC shall develop and implement an evacuation plan for inmates and staff and ensure that comprehensive fire drills are conducted every three months on each shift. CCDOC shall document these drills, including start and stop times and the number and 44

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location of inmates who were moved as part of the drills.
73. DFM shall ensure that the Facility has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable fire codes. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures in accordance with City of Chicago Fire Code (13­ 76-010).
74. DFM shall ensure that all fire and life safety equipment is properly maintained and routinely inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the Life Safety Equipment.
75. CCDOC shall continue to 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.
76. CCDOC 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. CCDOC shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall communicate with DFM via the Work Order System regarding lock-related issues and maintenance.
77. DFM shall develop and implement an annual preventative maintenance program concerning 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.
78. CCDOC shall implement competency-based testing for staff regarding fire and emergency procedures.
79. CCDOC shall promptly notify DFM of all electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires.
80. DFM shall promptly repair all known electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires and will document repairs by the Work Order System.
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81. CCDOC shall ensure that combustibles are controlled and eliminate highly flammable materials throughout the facility and inmate living areas (e.g., inmates’ use of paper bags as trash receptacles, ripped fire-retardant mattress covers, improvised cell light covers, blankets on cell floors, and improperly stored and labeled flammable liquids and other chemicals).
82. CCDOC 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.
G. SANITATION AND ENVIRONMENTAL CONDITIONS
83. Sanitation and Maintenance of Facilities
a. DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate maintenance of the Facility.
b. CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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.
c. DFM 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.
d. CCDOC shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting, and ventilation problems.
e. DFM shall ensure adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on an annual basis for non-automated systems.
f. CCDOC shall notify DFM of any visible obstructions to the ventilation system.
g. Cook County shall ensure adequate lighting in all inmate housing and work areas. 46


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 47 of 60
h. CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.
i. CCDOC shall ensure that all inmates have access to needed hygiene supplies.
j. CCDOC shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correctional standards. CCDOC 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.
k. DFM shall develop a policy on hazardous materials storage, in accordance with generally accepted correctional standards, and insure that all DFM staff is properly trained on the procedure.
l. CCDOC shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
m. CCDOC shall inspect and replace as often as needed all frayed and cracked mattresses. CCDOC shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. CCDOC shall ensure that mattresses are properly sanitized between uses.
n. CCDOC shall ensure adequate control and observation of all housing units, including distribution and collection of razors and cleaning supplies. All cleaning tools and hazardous chemicals shall be removed from housing areas after use.
o. CCDOC shall ensure that Facility sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.
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84. Sanitary Laundry Procedures
a. CCDOC shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted correctional standards. To limit the spread of communicable disease, CCDOC shall ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and dry.
b. CCDOC shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
c. CCDOC shall train staff and educate inmates regarding laundry sanitation policies.
d. CCDOC 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. CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
85. Food Service
a. CCDOC shall ensure that food service at the Facility is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures.
b. CCDOC shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
c. CCDOC shall ensure that the Central Kitchen and Division XI kitchen are staffed with a sufficient number of appropriately supervised and trained personnel.
d. CCDOC 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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e. CCDOC 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.
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and 49

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implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
IV. MONITORING
A. Monitor Selection: The parties have jointly selected Ms. Susan McCampbell to serve as the monitor for the CCDOC corrections provisions of the Agreed Order (“Corrections Monitor”). The parties have jointly selected Dr. Ronald Shansky to serve as the monitor for the medical provisions of this Agreed Order (“Medical Monitor”). The parties have jointly selected Dr. Jeffrey Metzner to serve as the monitor for the mental health provisions of this Agreed Order (“Mental Health Monitor”). The parties have jointly selected Mr. Harry Grenawitzke to serve as monitor for the physical plant (§§ III.F and III.G), DFM, and Capital Planning provisions of this Agreed Order (“Physical Plant Monitor”). With provisions that involve overlap between two disciplines, such as § III.B, Elements Common to Medical and Mental Health, the relevant Monitors shall coordinate in order to determine the proper manner for the necessary compliance assessment. Should any of the monitor positions become vacant and the parties cannot agree on a replacement, the parties shall recommend candidates to the Court, and the Court will appoint the Monitor. Neither party, nor any employee or agent of either party, shall have any supervisory authority over the Monitors’ activities, reports, findings, or recommendations. The cost for the Monitors’ fees and expenses shall be borne by Defendants. The selection of the Monitors shall be conducted solely pursuant to the procedures set forth in this Agreed Order, and will not be governed by any formal or legal procurement requirements. The Monitors may be terminated only for good cause, unrelated to the Monitors’ findings or recommendations, and only with prior notice to, and approval of, the parties or by Court order. Should all the parties agree that a Monitor is not fulfilling his or her duties in accordance with this Agreed Order, the parties may petition the Court for the Monitor’s immediate removal and replacement. One party may unilaterally petition the Court for the Monitor’s removal for good cause, and the other parties will have the opportunity to respond to the petition.
B. Monitor Qualifications: The Monitors shall have appropriate experience and education or training related to the subject areas covered in this Agreed Order.
C. Monitoring Team: The Monitors may hire or consult with such additional qualified staff as necessary to fulfill the duties required by the Agreed Order (“Monitoring Teams”). The Monitors are ultimately responsible for the findings regarding compliance. The Monitoring Teams will be subject to all the same access rights and confidentiality
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limitations, listed below, as the Monitors. The parties reserve the right to object for good cause to members of the Monitoring Teams.
D. Monitor Access: The Monitors shall have full and complete access to the Facility, all Facility records, inmate medical records, staff, and inmates. Defendants shall direct all employees to cooperate fully with the Monitors. All non-public information obtained by the Monitors shall be maintained in a confidential manner.
E. Monitor Ex Parte Communications: The Monitors shall be permitted to initiate and receive ex parte communications with all parties.
F. Limitations on Public Disclosures by Monitors: Except as required or authorized by the terms of this Agreed Order or the parties acting together, the Monitors shall not: make any public statements (at a conference or otherwise) or issue findings with regard to any act or omission of Defendants or their agents, representatives or employees, or disclose nonpublic information provided to the Monitors pursuant to this Agreed Order. Any press statement made by the Monitors regarding his or her employment must first be approved in writing by all parties. The Monitors shall not testify in any other litigation or proceeding with regard to any act or omission of Defendants or any of their agents, representatives, or employees related to this Agreed Order, nor testify regarding any matter or subject that he or she may have learned as a result of his or her performance under this Agreed Order. Reports issued by the Monitors shall not be admissible against Defendants in any proceeding other than a proceeding related to the enforcement of this Agreed Order by Defendants or DOJ. Unless such conflict is waived by the parties, the Monitors shall not accept employment or provide consulting services that would present a conflict of interest with the Monitors’ responsibilities under this Agreed Order, 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 Monitors are not a State/County or local agency or an agent thereof, and accordingly the records maintained by the Monitors shall not be deemed public records subject to public inspection. Neither the Monitors nor any person or entity hired or otherwise retained by the Monitors to assist in furthering any provision of this Agreed Order shall be liable for any claim, lawsuit or demand arising out of the Monitors’ performance pursuant to this Agreed Order. This provision does not apply to any proceeding before a court related to performance of contracts or subcontracts for monitoring this Agreed Order.
G. Monitors’ Reports: The Monitors shall file with the Court and provide the parties with reports describing the steps taken by Defendants to implement this Agreed Order and evaluate the extent to which Defendants have complied with each substantive provision
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of the Agreed Order. The Monitors shall issue an initial report four months after the effective date of this Agreed Order, 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 of individual inmates and staff and the interest of Defendants in protecting against disclosure of non-public information.
H. Compliance Assessments: In each Monitors’ report, the Monitors shall evaluate the status of compliance for each relevant provision of the Agreed Order using the following standards: (1) Substantial Compliance; (2) Partial Compliance, and (3) Non-compliance. In order to assess compliance, the Monitors 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 Monitors shall be responsible for independently verifying representations from Defendants regarding progress toward compliance, examining supporting documentation where applicable. Each Monitor’s report shall describe the steps taken to analyze conditions and assess compliance, including documents reviewed and individuals interviewed, and the factual basis for each of the Monitor’s findings.
I. Budget: The parties acknowledge that compliance with certain provisions of this Agreed Order will require additional expenditure of funds. The parties also acknowledge that the budget for CCDOC, Cermak, and DFM is subject to approval by the Cook County Board of Commissioners.
J. Monitors’ Budget: Defendants shall provide the Monitors with a budget sufficient to allow the Monitors to carry out the responsibilities described in this Agreed Order. The Monitors shall pay the members of the Monitoring Teams out of this budget. Prior to selection for the Monitors’ positions, each Monitor candidate proposed a reasonable, estimated budget sufficient to cover the responsibilities described in this Agreed Order.
K. Technical Assistance by the Monitors: The Monitors shall provide Defendants with technical assistance as requested by Defendants.
V. REPORTING REQUIREMENTS AND RIGHT OF ACCESS
A. Defendants shall each submit semiannual compliance reports to DOJ and the Monitors, the first of which shall be filed within six months of the date of this Agreed Order. Thereafter, the semiannual reports shall be filed 15 days after the termination of each sixmonth period thereafter until the Agreed Order is terminated.
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B. Each compliance report shall describe the actions Defendants have taken during the reporting period to implement this Agreed Order and shall make specific reference to the Agreed Order provisions being implemented.
C. Defendants shall maintain sufficient records to document that the requirements of this Agreed Order are being properly implemented and shall make such records available to DOJ at reasonable times for inspection and copying. In addition, Defendants 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.
D. DOJ and its attorneys, consultants, and agents shall have unrestricted access to the Facility, inmates, staff (including CCDOC, DFM, and Cermak staff, or staff from any other outside medical or mental health services provider), and documents as reasonably necessary to address issues affected by this Agreed Order.
E. Within 30 days of receipt of written questions from DOJ concerning Defendants’ compliance with the requirements of this Agreed Order, Defendants shall provide DOJ with written answers and any requested documents.
F. CCDOC and Cook County shall each appoint a compliance coordinator to oversee compliance with this Agreed Order and to serve as a point of contact.
G. Whenever any Defendant invokes exigent circumstances to take action that departs from what would otherwise be the requirements of this Agreed Order, that Defendant shall, immediately upon taking such action, notify the Monitors and DOJ of the exigent circumstances relied upon, the corresponding action taken, what it believes will be the duration of such circumstances and such action, and the steps it is taking to attempt to limit the duration of such action to as short a term as practicable.
VI. ENFORCEMENT
A. During the period that the Agreed Order is in force, if any of the Monitors or DOJ determines that a Defendant has not made material progress toward substantial compliance with a significant obligation under the Agreed Order, and such failure constitutes a violation of inmates’ constitutional rights, DOJ may, but is not required to, seek enforcement of the Agreed Order in Court.
B. Prior to taking judicial action to enforce the Agreed Order, DOJ shall give Defendants 53

Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 54 of 60
written notice of its intent to seek enforcement of the Agreed Order, and the parties shall engage in good-faith discussions to resolve the dispute.
C. The relevant Defendant(s) shall have 30 days from the date of such notice to cure the failure (or such additional time as is reasonable due to the nature of the issue and agreed upon by the parties) and provide DOJ with sufficient proof of its cure. At the end of the 30-day period (or such additional time as is reasonable due to the nature of the issue and agreed upon by the parties), in the event that DOJ determines that the failure has not been cured, DOJ may seek judicial action without further notice. DOJ commits to work in good faith with Defendants to avoid enforcement actions.
D. The terms of this Agreed Order are not subject to state or federal court enforcement by anyone other than DOJ.
E. In case of an emergency posing an immediate threat to the health or safety of an inmate or staff member at the Facility, however, DOJ may omit the notice and cure requirements herein before seeking enforcement of the Agreed Order.
VII. CONSTRUCTION, IMPLEMENTATION AND TERMINATION
A. Defendants shall implement all reforms within their areas of responsibility, as designated within the provisions of this Agreed Order, that are necessary to effectuate this Agreed Order. The implementation of this Agreed Order will begin immediately upon the effective date.
B. Except where otherwise agreed to under a specific provision of this Agreed Order, Defendants shall implement of all provisions of this Agreed Order within 180 days of the entry of this Agreed Order.
C. This Agreed Order shall terminate when Defendants have achieved substantial compliance with each of the provisions of the Agreed Order and have maintained Substantial Compliance with the Agreed Order for a period of 18 months. The parties anticipate that Defendants will have achieved substantial compliance with all provisions of the Agreed Order within four years of the Agreed Order’s Effective Date and sustained compliance with each such provision for at least 18 months. The parties agree that a full substantive section of the Agreed Order (§ III.A: Protection from Harm, § III.B: Health Care Services, § III.C: Medical Care, § III.D: Mental Health Care, § III.E Suicide Prevention Measures, § III.F: Fire and Life Safety, § III.G: Sanitation and Environmental Conditions, or § III.H: Quality Management and Performance Measurement) may conclude independently of the rest of the Agreed Order in the event 54


Case 1:10-cv-02946 Document 3-1 Filed 05/13/10 Page 55 of 60
that substantial compliance for all subcomponents of each provision in the full substantive section is achieved and maintained for the requisite 18-month period. In addition, if the responsible Defendant has substantially complied with all of the provisions assigned to it in a full substantive section of the Agreed Order (for example, CCDOC could substantially comply with all of the provisions specifically assigned to it in § III.C: Medical Care), and has maintained Substantial Compliance with all of those provisions for at least 18 months, those provisions may conclude independently of the rest of the Agreed Order. The burden shall be on the Defendant(s) to demonstrate this level of compliance. Non-compliance with mere technicalities, or temporary failure to comply during a period of otherwise sustained compliance will not constitute failure to maintain Substantial Compliance. At the same time, temporary compliance during a period of sustained Non-compliance shall not constitute Substantial Compliance.
D. The parties agree that every two years following the effective date of this Agreed Order, the Court shall conduct a status conference regarding the status of Defendants’ compliance with this Agreed Order.
E. Failure by any party to enforce this entire Agreed Order or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreed Order.
F. If any unforseen circumstance occurs that causes a failure to timely carry-out any requirements of this Agreed Order, Defendants shall notify DOJ in writing within 20 calendar days after Defendants become aware of the unforseen circumstance and its impact on the Defendant’s ability to perform under the Agreed Order. The notice shall describe the cause of the failure to perform and the measures taken to prevent or minimize the failure. Defendants shall implement all reasonable measures to avoid or minimize any such failure.
G. This Agreed Order shall constitute the entire integrated Agreed Order of the parties. With the exception of DOJ’s findings letter, referenced in provision I.4 herein, and any DOJ technical assistance recommendations, no prior or contemporaneous communications, oral or written, will be relevant or admissible for purposes of determining the meaning of any provisions herein in this litigation or in any other proceeding.
H. Nothing herein shall be deemed, construed, or interpreted as an admission of liability by Defendants. Neither this Agreed Order, nor any part thereof, shall be admissible against Defendants except in a proceeding involving the parties to this Agreed Order. Furthermore, by entering into this Agreed Order, Defendants do not waive the right to
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contest the July 11, 2008 findings letter or any of the conclusions set forth therein. I. The Agreed Order shall be applicable to, and binding upon, all parties, their officers,
agents, employees, assigns, and their successors in office. J. Each party shall bear the cost of its fees and expenses incurred in connection with this
cause. K. In the event that any provision of this Agreed Order is declared invalid for any reason by
a court of competent jurisdiction, said finding shall not affect the remaining provisions of this Agreed Order.
VIII. STIPULATION PURSUANT TO THE PRISON LITIGATION
 REFORM ACT, 18 U.S.C. § 3626

A. For the purposes of this Agreed Order only and in order to settle this matter, the parties stipulate that this Agreed Order complies in all respects with the provisions of 18 U.S.C. § 3626(a). The parties further stipulate and agree that the prospective relief in this Agreed Order is narrowly drawn, extends no further than necessary to correct the violations of federal rights alleged by the United States, is the least intrusive means necessary to correct these violations, and will not have an adverse impact on public safety or the operation of a criminal justice system. Accordingly, the parties agree and represent that the Agreed Order complies in all respects with the provisions of 18 U.S.C. § 3626(a).
B. The issue of liability has not been litigated. C. This Agreed Order is not intended to have any preclusive effect except between the
parties. Should the issue of the preclusive effect of this Agreed Order be raised, the parties agree to certify that this Agreed Order was intended to have no such preclusive effect.
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 UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS

UNITED STATES OF AMERICA,
Plaintiff,
v.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants,

No. 10 C 2946 Judge Virginia Kendall

Corrections Monitor Susan W. McCampbell’s Report No. 10 May 27, 2015

Susan W. McCampbell, President McCampbell and Associates, Inc. 1880 Crestview Way Naples, Florida 34119-3302 (239) 597-5906 Email: susanmccampbell@mccampbellassoc.com
Report # 10 May 27, 2015

Executive Summary
Corrections Monitor Susan W. McCampbell’s Report #10 DRAFT 5/7/15
Summary Overview
This document reports on the compliance in the Cook County Dept. of Corrections (CCDOC) for the 77 paragraphs in the Agreed Order related to inmate protection from harm. CCDOC is now in substantial compliance with all provisions of the Agreed Order.
I toured CCDOC from April 13 – 16, 2015. At the start of that week there were 8,928 inmates in custody (on the campus). During this tour I interviewed staff and inmates, reviewed documents, and consulted with CCDOC regarding compliance issues. I also participated in a briefing for the Honorable Virginia Kendall regarding compliance and progress.
The draft of this compliance report was provided to the parties on May 7, 2015, requesting all comments by May 21, 2015. I considered all comments in the preparation of this report.
Progress and Sustainability
Progress is achieved in the following areas:
• Implementation of the inmate classification system; • Continued improvement and refinements to monitor uses of force, including data
collection, analysis, and staff resources; • Continued hiring; • Designation of an inmate population manager to track inmates whose pre and post
trial incarceration clog the jail and identify and advocate for those who serve more time in the jail awaiting trial than the maximum sentence allowable for the charge on which the inmate will ultimately be sentenced;1 • Implementation of a much enhanced incident reporting system (CCOMS); and • On-going maintenance of compliance with 69 paragraphs of the Agreed Order found previously to be in compliance.
Notable is that CCDOC has develop internal monitoring and review systems that provide the department with the ability to collect and analyze data about all areas of operations

1 http://wgntv.com/2014/06/11/stuck-in-cook-county-jail/ accessed on 4/18/15; http://www.chicagotribune.com/news/watchdog/ct-jail-prison-turnaround-met-20150412story.html#page=1 accessed 4/18/15; http://www.chicagotribune.com/news/local/ct-cook-jail-beatingdeath-met-20150216-story.html#page=1 accessed 4/18/15; http://www.cookcountysheriff.com/MentalHealth/MentalHealth_main.html accessed on 4/18/15.

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(e.g., inmate discipline, inmate grievances, uses of force) and take actions to address any emerging trends. This is the philosophy and operational practice that assures sustainability of the improvements made during the source of the Agreed Order.

Remaining Challenges

Continuing challenges include, but are not limited to:

• Systemic, sustainable strategies to solve jail crowding; although jail population is down, the endemic issues remain, including development and sustainability of a collaborative justice system;
• Developing the work plan and data collection to validate the updated classification system by the next monitor’s tour in December 2015.
• A funded plan to replace outdated, maintenance-expensive, and staff-intensive facilities;
• Providing oversight and training to officers working in the direct supervision units in RTU/Div 8 relating to security and inmate safety;
• Fully staff Cermak’s mental health staff and mitigate the impact of Cermak mental health vacancies on CCDOD and inmate harm; and
• Continuing vigilance regarding reviews of uses of force and investigation of allegations of excessive force

Progress

This chart summarizes the progress made by CCDOC since my first report of September 20, 2010.

Report #
1 2 3 4 5 6 7 8 9 10

Sustained Compliance (more than 18 months)
21 35 50 68 69

Substantial Compliance
3 1 22 39 53 39 31 17 9 8

Partial Compliance
62 63 55 34 20 17 11 10 0 0

NonCompliance
12 5 0 0 0 0 0 0 0 0

Not Applicable
8 8 4 4 4 0 0 0 0 0

Total
77 77 77 77 77 77 77 77 77 77

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Compliance Report

The Agreed Order regarding corrections operations (A. Protection from Harm) includes 77 provisions. All provisions are in substantial compliance as of the tour in late September 2014.

Maintenance of Substantial Compliance (18 months) (N= 69)

The CCDOC has maintained substantial compliance with the following provisions of the Agreed Order for at least 18 months, and as such, are no longer a primary focus of my monitoring, although these sections remain an active part of the Order (see Section VII.C.). The paragraph maintaining substantial compliance added since the Report # 9 to the Court is underlined.

• 31.a. • 31.b. • 31.c. • 31.d. • 31.e. • 31.f. • 31.g. • 31.h. • 31.i. • 31.j. • 31.k. • 31.l. • 31.m. • 31.n. • 31.o. • 31.p. • 31.q. • 31.r.

• 31.s. • 31.t. • 32.a. • 32.b. • 32.c. • 32.d. • 32.e. • 32.f. • 32.g. • 32.h. • 32.i. • 32.j. • 32.k. • 32.l. • 32.m. • 33.a. • 33.c.i.ii. • 33.i.

• 33.j. • 34.a. • 34.b. • 34.c. • 34.d. • 34.e. • 34.f. • 34.g. • 35.a. • 34.b. • 35.c. • 35.d. • 35.e. • 35.f. • 35.g. • 36.a. • 36.b. • 36.c.

• 36.d. • 36.e. • 36.f. • 37.c. • 37.d. • 37.e. • 38.a. • 38.b. • 38.c. • 38.d. • 39.a. • 39.b. • 40. • 41. • 69.

Substantial Compliance (N=8)

Paragraphs for which CCDOC has maintained substantial compliance since the tour of September 2014 (e.g. 6 months):

• 33.b. • 33.d. • 33.e.

• 33.f. • 33.g. • 33.h

• 37.a. • 37.b.

Partial Compliance (N=0)

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There are no paragraphs in partial compliance. Non-Compliance (N=0)

There are no paragraphs in non-compliance.

Updates: Issues and Concerns About Achieving and Sustaining Substantial Compliance

Compliance with the Agreed Order/Cermak – I reiterate my concern that mental health staffing continues to fall short of the needs of the jail’s inmate population. As noted by the psychiatric monitor, the Cermak mental health staff in place are doing the best they can. However, Cermak’s inability to hire and retain mental health staff,, in my opinion, negatively impacts the safety of inmates and staff.

As I noted in my last report I recommend: • the implementation of a crisis intervention team to respond to incidents involving inmates with mental illness (CIT), • clarification of policies regarding involuntary psychotropic medications, • clarification of the operational practices regarding the safety, and/or perceived safety, of Cermak staff, • focus on specialization for corrections staff assigned and/or volunteering to work with inmates with mental illness, and • timely provision of documentation (anatomical charts) and medical records to facilitate CCDOC’s Office of Professional Responsibility’s investigations into allegations of use of excessive force.

While it is more than unfortunate that the jail has ended up as the mental health hospital for the County, this does not relieve the CCDOC from providing trained officers to oversee and supervise this population. Prior reports have urged CCODC to (1) implement system for assigning officers based on their interest and skill at working with mental health clients (as opposed to the system now where officers bid to posts with more of an eye toward days off and shifts than assignment responsibilities), (2) providing specialized training, and (3) actively including officers as part of the treatment team. This, in my view, remains an unresolved priority. While not specifically part of the Agreed Order, such ambitious and aggressive staffing protocols will benefit the mental health clients, officer safety and continuity of care.

Update: Information System – The new jail management information system, Cook County Offender Management System (CCOMS) was operational on October 26, 2014.

Investigations into Allegations of Use of Force/Excessive Force – An unintended outcome of the Hudson litigation has been continued priority on the investigative processes in the Cook County Sheriff’s Office. This level of scrutiny, which most jails in my opinion would be unable to withstand, demonstrated that the systems in place

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work. That is not to say that continuous focus and improvements are not beneficial, but the systems are in place.

Classification Implementation Progress – The revised inmate classification system was implemented on October 26, 2014. While the process rollout was mostly without issues, as expected a few tweaks to the software were required. The next step in the process is to gather and analyze data to determine if the system is ensuring inmate and staff safety. This review should be ready for the tour in December 2015.

New Jail Facilities/Renovation of Existing Jail Facilities – In January 2015 eight staff from CCDOC and the County’s Capital Planning attended the program Planning for New Institutions (PONI) offered by the National Institute of Corrections. This was a critical step to identifying HOW the next facility(ies) will be planned to avoid another RTU. In my opinion, the RTU is poorly designed for a number of reasons – such as no floor drains or electric outlets to facilitate daily cleaning of holding cells, cells in which there is insufficient sight lines, bars placed inside glazing, overengineering of sally ports, and lack of program space and square footage in housing units. The poor design results in higher staffing needs, the most expensive part of jail operations.

The County has indicated it wishes to demolish some of the existing aging infrastructure. While perhaps a positive step, recognizing that some physical plants are not worth the expensive of repair/refurbishing, the lack of a plan for what might replace these structures is glaringly absent. The newly implemented inmate classification system will inform the process of design by clearly indicating the type of beds and architecture needed (e.g. minimum, medium, max custody). If Cermak is properly staffed, the medical and mental health needs of inmates can be identified, expanded specialized housing can also be identified.

Whatever the County and Sheriff decide is the next construction needed, the lessons learned from the RTU need to be a priority, with a joint commitment to collaborative planning between corrections professionals and County staff, and incorporation of use of best practices. Additionally, if direct supervision is the architecture selected, attention needs to be paid to the number of inmate beds per unit, allowance for programming, and privacy in toilet and shower areas. Training for both line officers and supervisors on the concepts and management philosophy needs to be in the forefront of operations.

Jails across the country are experiencing lower inmate populations. While this is good news for a variety of reasons, research can’t explain why the numbers went down, so the numbers can easily go back up. Focused planning on reforming local justice system will have positive effect on alternatives to pre-trial detention, but at the same time, responsible leaders are planning for what challenges are ahead. As it takes about 10 years to plan and design a new jail, this is a process I recommend to Cook County.

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Jail Beds/Crowding/Inmates with Mental Illness – The Sheriff continues to educate the public, stakeholders and criminal justice partners of the critical need to address the impact of those with mental illness in the community who end up in jail. Data provided by CCDOC to decision-makers about the number of “dead days” – those spent by inmates needlessly caught in the justice system, and the documentation about individuals held longer in custody awaiting trial than if they had been sentences for their crimes are compelling reasons for a cogent community response.
Conclusions
CCDOC has achieved 100% substantial compliance with all paragraphs of the Agreed Order for which I am responsible for monitoring. As with all major reform efforts, progress has not always been a straight line, but rather has incorporated and embraced lesson learned, responses to resource availability, and identification of best practices.
CCDOC is commended and congratulated on reaching this milestone. Per the Agreed Order’s provision ,monitoring will continue for 12 months to assure that reforms are sustainable.

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Administrative Release Program (ARP)
This Executive Summary reports on the Administrative Release Program, designed to limit jail crowding when the population is more than 85% of capacity. The program is operated by the Sheriff’s Office. The following data was provided by the Cook County Sheriff’s Office regarding their review of candidates for release through this program.

Number Reviewed To Magistrates Ordered Males Placed Females Placed NPTS Refused Case Adjudicated Bond Out Medical
* May 4, 2015

2011

2012

2375

10061

237

859

78

572

22

246

13

85

130

25

40

89

2013 21879 3967 2503
945 377 662 62 189 215 53

2014 14039 2442 1319
449 171 445 24 47 72 63

2015 YTD* 3861 502 245 98 29 77 10 10 20 11

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UNITED STATES OF AMERICA VS. COOK COUNTY, ET. AL. Civil No. CV-02946
Corrections Monitor’s 10th Report
Based on the Tour Week of April 13, 2015

Substantial Compliance
Partial Compliance
Noncompliance

Section (Page)

A.

Protection from Harm

Language

31. (21) A. 31. a.

Use of Force by Staff
CCDOC shall maintain comprehensive and contemporary policies and procedures, in accordance with generally accepted correctional standards, surrounding the use of force and with particular emphasis regarding permissible and impermissible uses of force.

A.31. b. A.31.c.

CCDOC shall maintain use of force policies and pre-service and in-service training programs for correctional officers and supervisors that address the following impermissible uses of force: 1. use of force as a response to verbal insults or inmate threats where there is no immediate
threat to the safety of the institution, inmates, or staff; 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 CCDOC has attempted a hierarchy of nonphysical alternatives that are documented; 3. use of force as punishment or retaliation; 4. use of force involving striking, hitting, or punching a restrained and non-combative 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, unless lethal force is justified; and 7. use of inappropriate or excessive force.
CCDOC shall maintain a policy to ensure that staff adequately and promptly report all uses of force, in accordance with generally accepted correctional standards.

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x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11
x 9/10 x 3/11 x 8/11

x12/11 x7/12 x2/13

x 9/10 x 3/11 x 8/11

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x9/13

x3/14

x9/14

x4/15

A.31.d. CCDOC shall require that use of force reports:

x12/11 x 9/10

1.

be written in specific terms in order to capture the details of the incident

x7/12 x 3/11

2.

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

x2/13 x 8/11

3.

include a description of the instrument(s) of restraint or control, if any, and the manner in x9/13

which it was used;

x3/14

4.

note whether an inmate disciplinary report was completed in connection with the

x9/14

incident that prompted the use of force;

x4/15

5.

describe the nature and extent of apparent and reported injuries sustained both by the

inmate and staff member;

6.

contain the date and time medical attention was actually provided;

7.

describe, in detailed, factual terms, the type and amount of force used as well as the

precise actions taken in a particular incident; 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.

A.31.e. CCDOC shall continue to require prompt review by the shift commander of all use of force

x7/12 x 9/10

reports. The shift commander’s review of use of force reports shall include review for

x2/13 x 3/11

completeness and procedural errors, as well as review of the substantive content. If the use of

x9/13 x 8/11

force report does not comply with provision 31.d. of this Agreed Order, the shift commander

x3/14 x12/11

shall return it to the reporting officer for revision and resubmission until it is compliant. If the shift

x9/14

commander believes a use of force may have been inappropriate or excessive, he or she shall x4/15

immediately refer the incident for investigation.

A.31.f. CCDOC shall ensure that senior management review of uses of force includes:

x12/11 x 9/10

1. a timely review of medical documentation of inmate injuries, if any is submitted, as provided x7/12 x 3/11

by Qualified Medical Staff, including documentation surrounding the initial medical

x2/13 x 8/11

encounter, an anatomical drawing that depicts the areas of sustained injury, and

x9/13

information regarding any further medical care;

x3/14

2. the inmate disciplinary report, if any, associated with the use of force; and

x9/14

x4/15

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3. the incident report, if any, associated with the use of force.

A. 31.g.

CCDOC [and Cermak] shall establish criteria that trigger referral for inappropriate or excessive use of force investigations, including but not limited to, documented or known injuries that are extensive or serious; injuries involving fractures or head trauma; injuries of a suspicious nature (including black eyes, injuries to the mouth, injuries to the genitals, etc.); and injuries that require treatment at outside hospitals.

A. 31. h. When CCDOC review of use of force reports, and supporting records if applicable, reveals that reports of a use of force are materially inconsistent, conflicting, or suspicious, CCDOC shall refer that use of force incident for internal investigation.

A.31.i.

CCDOC 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. medical care provided (if applicable); 8. staff involved; 9. reviewing supervisor; 10. external reviews and results (if applicable); 11. remedy taken (if appropriate); and 12. administrative sign-off.

x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11 x7/12 x/2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 3/11 x 9/10 x 8/ll
x 9/10 x 3/11 x 8/11
x 9/10 x 3/11 x 8/11 x12/11

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A.31.j.

CCDOC shall ensure that, promptly following a use of force incident, video or photographs are taken of any and all reported or apparent injuries sustained by inmates and staff. The video or photographs will be maintained and will be included in the investigation package, if applicable. See 31. F.

A.31.k. A.31.l.

CCDOC shall establish an “early warning system” that will document and track correctional officers who are involved in use of force incidents and any complaints related to the inappropriate or excessive use of force, in order to alert CCDOC administration to an potential need for retraining, discipline, problematic policies, or supervision lapses. Appropriate CCDOC leadership, supervision, and investigative staff shall have access to the information and monitor the occurrences. CCDOC senior management shall use information from the early warning system to improve quality management practices, identify patterns and trends, and take necessary corrective action both on an individual and systemic level. CCDOC shall ensure that a supervisor is present during all pre-planned uses of force, such as cell extractions.

A.31.m. A.31.n.

Where there is evidence of staff misconduct related to inappropriate or unnecessary use of force against inmates, CCDOC shall initiate personnel actions and seek disciplinary action appropriately for any correctional officer found to have: 1. engaged in inappropriate or excessive use of force; 2. failed to report or report accurately the use of force; 3. retaliated against an inmate or other staff member for reporting an inappropriate or
excessive use of force; or 4. interfered or failed to cooperate with an internal investigation regarding use of force in a
manner inconsistent with the staff member’s statutory or contractual rights. Where there is evidence of staff misconduct related to inappropriate or unnecessary use of force against inmates, CCDOC shall consider, develop, and initiate systemic remedies as

x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15
x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11

x 9/10 x 3/11 x 8/11
x 9/10 x 3/11 x 8/11 x12/11
x 9/10 x 3/11 x 8/11
x 9/10 x 3/11 x 8/11
x 9/10 x 3/11

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appropriate.

A.31.o

CCDOC shall maintain accountability policies and procedures for the effective and accurate maintenance, inventory, and assignment of chemical and other security equipment, in accordance with generally accepted correctional standards.

A.31.p. A.31.q.

CCDOC shall continue to conduct use of force training in accordance with generally accepted correctional standards, including: 1. CCDOC shall maintain an effective and comprehensive use of force training program. 2. CCDOC shall continue to ensure that correctional officers receive adequate training in
CCDOC’s use of force policies and procedures, including de-escalation and defensive tactics relating to use of force. 3. CCDOC shall continue to ensure that correctional officers receive pre-service and in-service training on reporting use of force and completing use of force reports.
CCDOC shall provide a process for inmates to report allegations of the inappropriate or excessive use of force orally to any CCDOC staff member; said staff member shall give the inmate the opportunity to reduce his or her report to writing through a grievance or complaint form without discouragement.

A.31.r.

Following a use of force, when CCDOC staff transport an inmate to receive medical care by Cermak, as necessary, the CCDOC staff member shall inform the Cermak staff member that the inmate was involved in a use of force.

x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11
x 9/10 x 3/11 x 8/11

x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13 X 9/10 x 3/11

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A.31.s.

Cermak shall ensure that, when providing medical treatment or assessment to an inmate following a use of force, Qualified Medical Staff document the inmate’s injuries, if any, and any medical care provided. Cermak shall provide CCDOC senior management [OPR] with a brief summary documenting the initial medical encounter following a use of force, including an anatomical drawing that depicts the areas of sustained injury, if any, and information regarding any further medical care. See 31.f.

A.31.t.
32. (23) 32. a.
32.b.

Cermak 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 or inmate-on-inmate abuse, that health care provider shall immediately: 1. report the suspected abuse to the Executive Director of the Office of Professional Review or
other appropriate CCDOC administrator; and 2. adequately document the matter in the inmate’s medical record.
Safety and Supervision
CCDOC shall maintain security and control-related policies, procedures, and practices that will result in a reasonably safe and secure environment for all inmates and staff, in accordance with generally accepted correctional standards. Coordinate with Grenawitzke
CCDOC shall maintain policies, procedures, and practices to ensure the adequate supervision of inmate work areas and trustees, in accordance with generally accepted correctional standards. Coordinate with Grenawitzke

32.c.

CCDOC shall ensure that security staff conduct appropriate rounds with sufficient frequency to provide inmates with reasonable safety. Rounds shall be conducted at least once every half
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x9/14 x4/15 x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x9/14 x4/15

x 9/10 x 3/11
x 3/11

x 9/10

x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x 2/13 x9/13 x3/14 x9/14 x4/15 x2/13 x9/13

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x 8/11 x12/11

x 9/10 x 3/11

x 9/10 x 3/11
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32.d.

hour, at irregular intervals, inside each housing unit. In the alternative, CCDOC may provide direct supervision of inmates by posting a correctional officer inside the day room area of a housing unit to conduct constant surveillance. More frequent rounds shall be conducted for special management inmates who require more intensive supervision for security and safety reasons. All security rounds shall be documented on forms or logs that do not contain preprinted rounding times. Video surveillance may be used to supplement, but must not be used to replace, rounds by correctional officers. CCDOC shall ensure that security supervisors conduct daily rounds in the inmate housing units, and document the results of their inspections.

32.e.

Cook County shall increase the use of overhead video surveillance and recording cameras to provide adequate coverage throughout the common areas of the Facility, including the RCDC, all division intake areas, mental health units, special management units, inmate housing units, and in common areas of the divisions.

x3/14 x9/14 x4/15
x2/13 x9/13 x3/14 x9/14 x4/15 x9/13 x3/14 x9/14 x4/15

X 8/11 x12/11 x7/12

x 3/11 x 8/11 x12/11 x7/12

x 9/10

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13

32.f. 32.g.
32.h.

CCDOC shall maintain a procedure to prevent inmates from possessing or having access to dangerous contraband, including conducting regular inspections of cells and common areas of the housing units to identify and prevent rule violations by inmates. CCDOC shall review, and revise as applicable, all General Orders (“GOs”), Standard Operating Procedures (“SOPs”), and Post Orders on an annual basis, or more frequently as needed.
CCDOC shall revise policies, SOPs, and post orders for all armed posts to include proper use and

x2/13 x9/13 x3/14 x9/14 x4/15 x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x12/11

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x 9/10 x 3/11
x 9/10

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32.i. 32.j. 32.k. 32.l.

safe handling of weapons and provide specific instructions on use of deadly force and when and under what circumstances such force should be used, in accordance with generally accepted correctional standards.
CCDOC shall standardize security policies, procedures, staffing reports, and post analysis reports across the divisions, to the extent possible, taking into account the different security levels and different physical layouts in the various divisions.
CCDOC shall provide formal training on division-specific SOPs to correctional officers in accordance with their assignments, and shall provide further specialized training for officers assigned to Special Management Units. Cermak Hospital shall provide Specialized training for officers assigned to psychiatric units. Coordinate with medical monitor and Dr. Metzner. See also 44.f., 44.g., 44.h., 46.b., 46.e., 68.
CCDOC shall maintain in working order all monitoring equipment at the Facility that is under CCDOC’s direct control, including cameras, alarms, radios (hand held), interior and exterior lighting, x-ray and other screening equipment, and walk-through metal detectors. To the extent that the maintenance of any Facility monitoring equipment is under the control of DFM, CCDOC shall promptly report any maintenance needs and DFM shall prioritize its services to ensure that all monitoring equipment is maintained in working order. Coordinate with Grenawitzke Absent exigent circumstances, CCDOC: (i) shall house each inmate assigned to a division that is celled to one permanent bed in a cell and shall not house any inmates (including those assigned to dormitory divisions) such that they are sleeping on the floor, on a mattress on the floor, or in any area not designed or redesigned as sleeping quarters; (ii) shall not house more than two inmates to a single cell (triple-bunking); and (iii) shall not hot-bunk any inmates.

x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15
x 8/112 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 3/11 x/8/11
x 9/10 x 3/11 x 8/11 x12/11 x7/12 x 9/10 x 3/11 x 8/11 x12/11
x 9/10 x 3/11 x 8/11 x12/11

2 Noted as “NA” in first two reports.

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32.m.
33.
33.a. (25)
33.b. (25)
33.c.i.ii

When exigent circumstances give rise to triple-bunking, CCDOC shall provide the third inmate in x 8/113

the triple-bunked cell a “boat,” stackable bunk, moveable platform, or cot, so that the inmate is x12/11

not required to lay down directly on the cell floor or on a mattress on the floor.

x7/12

x2/13

x9/13

x3/14

x9/14

x4/15

Security Staffing.

The parties agree that correctional officer staffing and supervision levels at the Facility must be appropriate to adequately

supervise inmates, to carry out the requirements of this Agreed Order, and to allow for the safe operation of the Facility,

consistent with generally accepted correctional standards. Cook County and CCDOC shall take such actions as shall

ensure that correctional officer staffing and supervision at the Facility are sufficient to achieve these purposes. These actions

shall include the following:

In the fiscal year 2010 budget, Cook County shall allocate funds sufficient to allow for 210

x 8/11 x 9/10

additional correctional officer positions at the Facility. Consistent with provision 33.c, such

x12/11 x 3/11

funding may occur on a rolling basis, as appropriate in light of the time required to hire, train,

x7/12

and put on duty the additional 210 new correctional officers.

x2/13 x9/13

x3/14

x9/14

x4/15

CCDOC shall use its best efforts (through the maintenance of the written staffing plan required

X9/14 x 9/10

by provision 33.h and otherwise) to ensure that the number of correctional officer vacancies is

x4/15 x 3/11

kept to the minimum practicable number at all times, taking into account that the timing of terminations and resignations and the resulting rate of attrition may, in ordinary course, result in there being some vacancies at any given time.

x 8/11 x12/11 x7/12 x2/13

x9/13

x3/14

CCDOC shall fill the 210 additional correctional officer slots provided for in provision 33.a; fill the x 8/11

x 9/10

3 Noted as “NA” in first two reports.

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(26)
33.d. (26) 33.e. (27)
33.f. (27) 33.g. (28)

285 correctional officer vacancies that existed at the Facility as of July 17, 2009; and fill any correctional officer vacancies coming into existence after that date in the following manner:
i. By December 31, 2010, CCDOC shall hire, train, and put on duty at the Facility at least 448 [381] newly qualified correctional officers (in addition to those on duty as of December 31, 2009). ii. By March 30, 2011, CCDOC shall hire, train, and put on duty at the Facility at least 174 [107] newly qualified correctional officers (in addition to those on duty as of December 31, 2010). The parties agree that for 30 months following the effective date of this Agreed Order, Cook County and CCDOC shall not be required to provide additional correctional officer staffing and supervision at the Facility beyond that which is necessary to ensure that correctional officer staffing and supervision are sufficient to achieve the purposes set out in the introductory paragraph of provision 33 and to comply with provisions 33.a-c above. Due date 11/13/2012 Within 30 months of the effective date of this Agreed Order, the CCDOC Monitor shall assess and make a recommendation on whether the correctional officer staffing and supervision levels are appropriate to adequately supervise inmates at the Facility, in accordance with generally accepted correctional standards. If the CCDOC Monitor determines that staffing is inadequate, the CCDOC Monitor will make a recommendation regarding the appropriate number of correctional officer staff. If the parties do not accept the CCDOC Monitor’s staffing recommendation, CCDOC and Cook County shall agree to an independent, comprehensive study to determine the appropriate correctional officer staffing and supervision. The parties agree that the results of this staffing study shall provide guidance as to the sufficient number of qualified correctional officers necessary to operate the Facility safely and to carry out the requirements of this Agreed Order. Due date 11/13/2012 If the staffing study requires additional correctional officers, Cook County shall allocate funds sufficient to maintain correctional officer staffing levels necessary to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards. Due date 11/13/2012 If the staffing study requires additional correctional officers, and consistent with Cook County’s allocation of funds for security staffing, CCDOC shall hire and train sufficient number of qualified correctional officers and other staff to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional

x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x9/14 x4/15
X9/14 x4/15
x9/14 x4/15
x9/14 x4/15

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x 3/11
x2/13 x9/13 x3/14 x9/14 x2/13 x9/13 x3/14 x9/14
x2/13 x9/13 x3/14 x2/13 x9/13 x3/14
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33.h. (28)

standards, including: 1. Investigative staffing sufficient to meet the internal investigation responsibilities outlined in this Agreed Order; 2. Correctional officer staffing sufficient to provide inmates requiring treatment with adequate access to appropriate medical and mental health care by providing timely movement of inmates to medical units, transport of inmates who have been referred for outside specialty care, and escort, if necessary, to Qualified Medical and Mental Health Staff on housing units; and [Coordinate with medical monitor and Dr. Metzner] 3. Qualified staff sufficient to monitor security cameras in real time and allow for supervisory viewing and retrieving at any time. Due date 11/13/2012
CCDOC shall maintain a written staffing plan that requires sufficient staffing to carry out the requirements of this Agreed Order and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards.

x9/14 x4/15

x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14

x 9/10 x 3/11

33.i. Absent exigent circumstances, CCDOC shall maintain a practice that does not allow for

x 8/114

(28) scheduled, planned, or expected cross-watching (a CCDOC practice of allowing one

x12/11

correctional officer to simultaneously supervise two housing units from the control center of one

x7/12

of the units) at any time on all maximum security and Special Management Units, and during first and second shifts throughout the Facility.

x2/13 x9/13 x3/14

x9/14

x4/15

33.j. CCDOC may permit cross-watching on third shift in housing units that are not maximum security x 8/115

(28) or Special Management Units only if the Monitor does not object after consultation and review. x12/11

The Monitor’s review of the appropriateness of third-shift cross-watching on a particular housing

x7/12

unit shall be guided by the sufficiency of sightlines between the units being cross-watched, the adequacy of video and/or audio technologies in place, and/or other factors that bear on the

x2/13 x9/13

4 Noted as “NA” in first two reports.

5 Noted as “NA” in first two reports.

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34. (29) 34. a.
34.b.

safety and security of inmates and staff. If the Monitor later objects to any cross-watching that is in effect because of the Monitor’s concerns that cross-watching on a particular housing unit presents an undue risk to the safety and security of inmates and staff, CCDOC shall immediately cease such cross-watching. CCDOC may renew cross-watching on that unit again if, after further consultation with and review by the Monitor, the Monitor does not object to such renewal. Although cross-watching is permitted under the limited circumstances described herein, CCDOC will work to eliminate the practice at the Facility. Incidents and Referrals
CCDOC shall continue to ensure that staff adequately and promptly document all reportable incidents, including inmate fights, rule violations, inmate injuries, suicides and suicide attempts, cell extractions, medical emergencies, contraband, vandalism, escapes and escape attempts, fires, and other incidents causing a disruption to standard CCDOC practice, in accordance with generally accepted correctional standards.
CCDOC shall continue to ensure that correctional officers receive pre-service and in-service training on proper incident reporting policies and procedures in accordance with generally accepted correctional standards.

34.c.

CCDOC shall maintain a system to track all reportable incidents (as described in provision 34.a) that, at a minimum, includes the following information: 1. incident tracking number; 2. the inmate(s) name; 3. housing assignment; 4. date; 5. type of incident; 6. injuries (if applicable); 7. medical care (if applicable); 8. primary and secondary staff involved;
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x3/14 x9/14 x4/15
x2/13 x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x 9/10 x 3/11
x 9/10 x 3/11 x 8/11 x12/11 x7/12
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34.d. 34.e. 34.f. 34.g.

9. reviewing supervisor; 10. external reviews and results (if applicable); 11. remedy taken (if appropriate); and 12. administrative sign-off. CCDOC shall require prompt administrative review of incident reports. Such reviews shall include a case-by-case review of individual incidents as well as a systemic review in order to identify patterns of incidents. CCDOC shall incorporate such information into quality management practices and take necessary corrective action.
CCDOC 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.
CCDOC shall maintain policies, procedures and practices requiring investigations to resolve issues identified during review of incident reports, disciplinary hearings, or inmate grievances, and determine appropriate remedies, in accordance with generally accepted correctional standards. At a minimum, CCDOC shall require timely and appropriate investigations of all suicides, serious suicide attempts, inmate-on-inmate violence resulting in serious injury, inmateon-staff violence, inmate injuries requiring treatment by an outside hospital, inmate injuries of a suspicious nature (including black eyes, injuries to the mouth, injuries to the genitals, etc.), sexual misconduct between inmates, sexual misconduct involving staff, fires, escapes, escape attempts, and deaths. CCDOC (OPR) shall ensure that any investigation reports indicating possible criminal behavior will be referred to the appropriate law enforcement authority.

x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x9/13 x3/14 x9/14 x4/15
x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14

x 9/10 x 3/11
x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13 x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13
x 9/10 x 3/11

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35. (30) 35.a. 35.b. 35.c.
35.d.

x9/14

x4/15

Investigations:

Investigations at the Facility are conducted by independent departments under the Cook County Sheriff’s Office, including

the Office of Professional Review, the Criminal Investigations Unit, and the Sheriff’s Police Department. The Cook County

Sheriff will assume responsibility for requiring these investigatory units to comply with the relevant provisions of this Agreed

Order.

CCDOC [OPR] shall maintain comprehensive policies, procedures, and practices for the timely

x2/13 x 9/10

and thorough investigation of alleged staff misconduct, in accordance with generally accepted x9/13 x 3/11

correctional standards.

x3/14 x9/14 x4/15

x 8/11 x12/11 x 7/12

Internal investigations [OPR] shall be conducted by persons who do not have supervisory

x 7/12 x 9/10

responsibility for the staff member(s) being investigated.

x2/13 x 3/11

x9/13 x 8/11

x3/14 x12/11

x9/14

x4/15

CCDOC [OPR] shall ensure that all internal investigations will include timely, thorough, and

x 9/10

documented interviews of all relevant staff and inmates who were involved in, or witnessed, the x 3/11

incident in question.

x 8/11

x12/11

x 7/12

x2/13

x9/13

x3/14

x9/14

x4/15

CCDOC [OPR] shall ensure that internal investigation reports shall include all supporting

x 9/10

evidence, including witness and participant statements, policies and procedures relevant to the x 3/11

incident, physical evidence, video or audio recordings, and relevant logs.

x 8/11

x12/11

x 7/12

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35.e.

CCDOC [OPR] shall ensure that all investigatory staff will receive pre-service and in-service training on appropriate investigations policies and procedures, the investigations tracking process, investigatory interviewing techniques, and confidentiality requirements.

35.f.

CCDOC [OPR] shall provide all investigators who will be assigned to conduct investigations of use of force incidents with specialized training in investigating use of force incidents and allegations.

35.g.

CCDOC [OPR] shall ensure that the results of each internal investigation shall be documented in an investigation report. CCDOC administration shall review the investigation reports, along with the underlying documentation, and take appropriate action. CCDOC shall implement appropriate remedies based upon the results of internal investigations.

36. (31) 36.a.

Inmate Disciplinary Process
CCDOC shall maintain policies, procedures, and practices for a formal disciplinary process, including prompt issuance of written disciplinary citations, administrative review and disciplinary reports for alleged minor rule violations, and due process for alleged major rules violations, in accordance with generally accepted correctional standards.

x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11 x12/11
x 9/10 x 3/11 x 8/11 x12/11
x 9/10 x 3/11 x 8/11 x12/11

x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11 x12/11

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Section (Page)

Language

36.b. CCDOC shall ensure that inmate disciplinary hearings are conducted in a reasonably private and secure setting.

36.c. 36.d.

CCDOC shall ensure that all inmates places in lock down status are provided with appropriate due process that has been developed and implemented in policies and procedures, in accordance with generally accepted correctional standards.
In an emergency, the Executive Director of CCDOC may order a lock down of entire areas of the Facility in order to control the situation and address serious security concerns. In such circumstances, it is not necessary to provide disciplinary hearings to each inmate affected by the lock down. However, lock downs of this nature shall be limited to only the time and scope necessary to address the emergency.
For the purposes of this Agreed Order, a “lock down” shall not include the routine instances in which inmates are confined to their cells, including periods of count, over night, shift change, movement, and routine contraband sweeps.
CCDOC shall ensure that the disciplinary board’s written record accurately reflects the testimony and discussion from the disciplinary hearing, including any recommendations from a mental health professional regarding the extent to which disciplinary charges are related to an inmate’s serious mental illness or suggestions for minimizing the deleterious effect of disciplinary measure on the mental health status of the inmate.

36.e. CCDOC shall alert Cermak when inmates are placed in disciplinary segregation or protective custody.

Report # 10 May 27, 2015

Substantial Compliance
Partial Compliance
Noncompliance

x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11
x 9/10 x 3/11 x 8/11 x12/11

x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 3/11 x 8/11 x12/11

x9/10

x7/12 x2/13 x9/13 x3/14 x9/14

x 9/10 x 3/11 x 8/11 x12/11
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Substantial Compliance
Partial Compliance
Noncompliance

Section (Page)

Language

36.f.

CCDOC shall permit a Cermak Qualified Mental Health Staff member to serve on the disciplinary board.

37. Classification

x4/15 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 3/11 x 8/11

x 9/10

37.a. (32)
37.b. (32)
37.c. (33)

CCDOC shall maintain policies and procedures for an appropriate, objective classification system that separates inmates in housing units by classification levels in order to protect inmates from unreasonable risk of harm. The system shall include consideration of an inmate’s security level, severity of current charge, types of prior commitments, suicide risk, history of escape attempts, history of violence, and special needs. CCDOC shall use best efforts to anticipate periods of unusual intake volume and schedule sufficient classification staff to timely classify inmates. CCDOC shall ensure that classification staff have sufficient access to current information regarding cell availability on each division.
CCDOC shall include information on each inmate’s assignment to the Special Incarceration Unit “level system” at the Facility in the new Jail Management System, starting with the date the new Jail Management System becomes operational.

x9/14 x4/15
x9/14 x4/15
x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13 x9/13

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x 9/10 x 3/11 x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14

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Substantial Compliance
Partial Compliance
Noncompliance

Section (Page)

Language

37.d. (33)
37.e. (33)
38. (33) 38.a.

CCDOC shall provide training and access to all correctional officer supervisors on the full capabilities of the new Jail Management System’s classification and inmate tracking system (or any replacement system).
CCDOC shall provide ongoing internal and external review and validation of the inmate classification system to ensure its reliability and objectivity.
Inmate Grievance Procedure
CCDOC shall maintain policies and procedures to ensure inmates have access to an adequate grievance process and to ensure that grievances may be accessed and filed confidentially, without requiring the intervention of a correctional officer, in accordance with generally accepted correctional standards. These policies and procedures should be applicable and standardized across all the Facility divisions.

x3/14 x9/14 x4/15 x2/13 x9/13 x3/14 x9/14 x4/15
x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11 x12/11 x7/12
x7/12 x2/13 x9/13

x 9/10 x 3/11 x 8/11 x12/11

x8/11 x12/11 x7/12 x9/14 x4/15

x 9/10 x 3/11 x2/13 x9/13 x3/14

38.b. 38.c.

CCDOC shall ensure that the grievances receive appropriate follow-up, including informing the grievant of the outcome, providing a timely written response, and tracking implementation of resolutions.
CCDOC shall ensure that grievance forms are available on all units and are available in Spanish. CCDOC shall ensure that there is adequate opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access the grievance system.

x 8/11 x12/11 x7/12 x9/14 x4/15
x 8/11 x12/11 x7/12 x9/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x2/13 x9/13 x3/14 x 9/10 x 3/11 x2/13

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Section (Page)

Language

38.d.

CCDOC shall ensure that inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, are referred for investigation. A member of the management staff shall review the grievance tracking system regularly in order to identify areas of concern.

39. (36) 39.a.
39.b.

Access to Information
CCDOC shall ensure that newly admitted inmates receive information, through an inmate handbook or orientation video, regarding the following areas: facility rules and regulations; how to report misconduct; how to report sexual abuse or assault; the process for accessing medical and mental health care; emergency procedures; rules for sending and receiving mail; the visitation process; facility schedule; the disciplinary process; and how to seek redress of grievances. CCDOC shall ensure that materials on facility rules and services are available for non-literate and non-English speaking inmates.

40. CCDOC shall provide training and supervision to all correctional officers and supervisors (36) sufficient to implement the provisions of this Agreed Order.

41. Inter-Agency Agreement (37) a. CCDOC shall enter into a written Inter-Agency Agreement with Cermak that delineates
the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
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Substantial Compliance
Partial Compliance
Noncompliance

x 8/11 x12/11 x7/12 x9/13 x3/14 x9/14 x4/15

x 3/11 x2/13

x 9/10

x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11 x 8/11 x12/11 x7/12

X2/13 x9/13 x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15 x 8/11 x12/11 x7/12 x2/13 x9/13

x 9/10 x 3/11 x 8/11 x12/11 x7/12 x 9/10 x 3/11
x 3/11 x 9/10
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Substantial Compliance
Partial Compliance
Noncompliance

Section (Page)
b.

Language
Cermak shall enter into a written Inter-Agency Agreement with CCDOC that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.

69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily (37) available, safely secured, suicide cut-down tools. *Coordinate with Dr. Metzner

x3/14 x9/14 x4/15
x 8/11 x12/11 x7/12 x2/13 x9/13 x3/14 x9/14 x4/15

x 9/10 x 3/11

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31. Use of Force
April 2015 - There are twenty (20) paragraphs in the Agreed Order regarding use of force. All these paragraphs have remained in substantial compliance for 18 months. While not citing each paragraph individually, below is provided an update on CCDOC’s progress in this critical area since the last tour.
In assessing CCDOC’s on-going compliance for these requirements I: • continued to review a weekly sample of use of force reports/videos; • interviewed inmates in Divisions 9, 1, and 3; • assessed the Use of Force Review Units’ statistics, analysis of uses of force, recommendations and actions; • reviewed the Inspector General’s report of the investigative process, organizational structure and chain of command; • examined several use of force investigative reports at the Office of Professional Responsibility (OPR); • read the updated/draft of revisions to the use of force policy; • reviewed the use of force lesson plans and incident reporting lesson plans and found it to be consistent with the Agreed Order and accepted practice; • assessed planned uses of force; • evaluated the number of pending use of force investigations in OPR; • met with Cermak, the Inspector General, and OPR staff regarding a reviewed process for insuring prompt production of inmate medical records; • reviewed workers’ compensation reports to compare the information to a sample of use of force reports; • examined staffing for the OPR and Use of Force Review Unit; • assessed “supplemental” training provided to employees identified through the early warning system re: uses of force, reporting, actions; • Data summary of inmate/inmate allegations for the last 15 months; • confirmed the progress of the video system throughout CCDOC facilities; • reviewed a list of training provided to OPR staff from September 2014 to present; • Review of UFRU findings for monitor-selected incidents; • Division 9 data regarding management of inmates; • examined the process and outcomes for the “early warning system”; • reviewed the process for leadership and management review of trends and remedies regarding uses of force; and • reviewed logs for chemical and other security equipment.

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I will soon have real time access to CCOMS to review reports, videos, and related materials regarding incidents in the jail. This opportunity to view the information in CCOMS is a means to systems check from the monitor without having to ask CCDOC staff to gather and transmit the information. My questions arise from my reading of the weekly summaries of incidents, which I have done since December 2010.
An outcome of the Hudson litigation6 is that CCDOC was able to assess, outside of the specific provisions of the Agreed Order, if their internal processes were insuring inmate safety. This was an examination that was not ever contemplated and an inadvertent systems’ check.
Judge Kendall found in her March 31, 2015 opinion that “The evidence presented at hearing demonstrated the Defendants have worked diligently – and with marked success in many areas – at combating the danger that exists at the Jail.”7 Judge Kendall also wrote “Plaintiffs have simply failed to supply evidence to support their claims that the Defendants have engaged in a pattern and custom of failing to investigate cases of excessive force or have investigated them in such a way that officers are intentionally exonerated.”8
It has been my experience that even in the best-managed jails when a process is “repaired” often attention and resources are diverted to other priorities – of which there are unfortunately many. In the Cook County Sheriff’s Office, because of the leadership’s commitment, the Office of Professional Responsibility and the Use of Force Review Unit have continued to be high priority activities. In fact, several processes put in place not required by the Agreed Order – for example the Use of Force Review Unit – as I noted in other reports, are now being replicated in other jails – large and small.
My conclusion is that while investigative processes continue to be refined, there is sufficient focus on preventing, reporting, investigating, and as necessary, correcting employees that sustainability can be anticipated. For example, two refinements to the systems are:
• The designation of “Squad 3” charged with preliminarily reviewing all allegations of excessive uses of force – no matter the source of the report – within 72 hours; and
• Placement of the Use of Force Review Unit placed under the chain

6 Tylon Hudson, et. al., v. Toni Preckwinkle, et. al. 1:13-cv-08752. 7 Case 1:13-cv-08752 Document #328 filed 3/31/15, Page 42. 8 IBID, Page 43.

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of command of the Inspector General (rather than previously under CCDOC) with the provision of additional staff resources.
Recommendations regarding this section of the Agreed Order are as follows: • Continue to monitor the investigative caseload to insure the timeliness of completion of the work, and assess if additional staffing resources are needed; • Place a priority on filling vacant positions in OPR whether through outside hiring or detailing qualified internal candidates; • Monitor employee discipline related to allegations of use of excessive force to identify opportunities to expeditiously handle discipline; • Continue to evaluate the use of supplemental training and its impact on the work related behavior of employees identified via the early warning system;9 • Continue to refine the data that evolves from the Use of Force Review Unit to inform all related aspects of correctional operations including, but not limited to employee training, supervision, and ongoing inmate training/orientation; • Develop plans of action identified through any trend analysis; and • Monitor uses of force involving inmates on the mental health caseload, and development, as needed, of collaborative approaches to managing this inmate population and provision of the required staffing of mental health professionals in Cermak.
It is regrettably true that jails are dangerous places due to a variety of reasons including the prevalence of serious mental illness among the inmate population; and, in a few instances, there are employees who engage in unacceptable practices and behavior. CCSO has developed systems to prevent, identify, report and investigate instances of allegations of serious staff misconduct no matter the source. All such systems require continual focus to insure ongoing refinements and success in the mission of preventing harm to staff and inmates.
32. Safety and Security
April 2015 - There are thirteen (13) paragraphs in the Agreed Order, which address safety and security. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work since the tour of September 2014.

9 For 2014, the majority of supplemental training for a total of 113 staff involved working with employees on improving report writing.

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In assessing CCDOC’s on-going compliance for these requirements I: • reviewed the status of the on-going annual updating process for written policies and procedures; • reviewed logs from each division regarding conduct of rounds; • was updated regarding the 1,800+ video cameras located throughout the jail system; • reviewed the “weapons free” reports regarding the detection, identification and prevention of contraband; • review of logs for equipment, radios, etc.; and • followed inmate population data trends.
CCDOC has consistently demonstrated the ability to provide updated policies and procedures and link those to in-service training. This includes both at the department and the divisional level.
CCDOC continues to have a robust procedure in place for finding and identifying, thus preventing introduction and fabrication of contraband. The introduction of contraband and fabrication by inmates of contraband is an on-going struggle in every penal institution. Even paperclips present opportunities for inmates to fashion keys and weapons. Particularly where there are old buildings, such as in the CCDOC system, contraband can be fashioned from unlikely sources. This can be seen in the data from CCDOC, for example, the prevalence of seizures in Division I. Also, the discovery of contraband in a medical setting is also evidenced by the number of recoveries in Cermak. CCDOC does a credible job of managing, educating, and coordinating especially with medical providers.
The current reduction in the inmate population has made the issue of bed space manageable. Division V remains closed. There is some inmate crowding in Cermak that should be addressed by appropriate management of the inmate’s medical housing options.
During the next tour I will reexamine the divisional level related training.
33. Security Staffing
33. Security Staffing. The parties agree that correctional officer staffing and supervision levels at the Facility must be appropriate to adequately supervise inmates, to carry out the requirements of this Agreed Order, and to allow for the safe operation of the Facility, consistent with generally accepted correctional standards. Cook County and CCDOC shall take such actions as shall ensure that correctional officer staffing and supervision at the Facility are sufficient to achieve these purposes. These actions shall

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include the following:

a.

In the fiscal year 2010 budget, Cook County shall allocate funds sufficient to allow

for 210 additional correctional officer positions at the Facility. Consistent with provision

33.c, such funding may occur on a rolling basis, as appropriate in light of the time required

to hire, train, and put on duty the additional 210 new correctional officers.

April 2015 Compliance Status: Substantial Compliance

Status Update: Remains in substantial compliance.

CCDOC data indicated there are 142 vacancies as of March 31, 2015, with 42 new hires anticipated by April 30th. An updated report documented 100 vacancies as of 5/1/15 with 55 hires planned by June 29, 2015. The projected hiring through the end of CY 2015 is 220. A schedule for preservice training was provided through 5/9/16. For CY 2015 year to date, CCDOC report that vacancies (N=89) were as a result of promotions/transfers (46%); retirements (13%); resignations (18%); terminations (15%); leaves of absence (most likely pending taking jobs in other law enforcement agencies)(6%), and deaths (2%). With some improvements in the economy, local law enforcement agencies are increasing hiring, impacting both the attrition of CCDOC and recruitment efforts.10 It appears in spite of increasing competition, CCDOC is able to attract, hire, train and deploy staff consistent with the approved staffing plan.

A review of the most recent budget submission to the County indicates that CCDOC is requesting a substantial increase in overtime funds (more than 100%) and an approximate 8% increase in total personnel spending. These funds will provide flexibility to CCDOD in terms of determining the point at which overtime is a better, or worse, option than hiring.

Monitor’s Assessment: As noted in the previous 9 reports, CCDOC is able to sustain hiring as required by the Agreed Order.

Monitor’s Recommendation: None at this time.

b.

CCDOC shall use its best efforts (through the maintenance of the written staffing

plan required by provision 33.h and otherwise) to ensure that the number of correctional

officer vacancies is kept to the minimum practicable number at all times, taking into

account that the timing of terminations and resignations and the resulting rate of attrition

may, in ordinary course, result in there being some vacancies at any given time.

10 http://patch.com/illinois/beverly-mtgreenwood/100-new-officers-added-chicago-police-force-0 accessed on 4/27/15, http://www.chicagotribune.com/news/ct-chicago-police-budget-hearing-met-1031-20141030story.html accessed 4/27/15.

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April 2015 Compliance Status: Substantial compliance

Status Update: Remains in Substantial Compliance.

Monitor’s Assessment: As noted in Report # 9 CCDOC memorialized the organization’s on-going staffing strategy in General Order 24.1.20.0, Centralized Roster Management Staffing Analysis. This directive, approved by the Department of Justice, requires an annual staffing review. This strategy will include three levels of review focusing on: (1) reducing overtime; (2) identifying barriers to achieving staffing objectives; and (3) responses to the barriers and challenges of staffing.

Monitor’s Recommendations: I will evaluate this paragraph during the next tour to assure the results of the three-step process are documented.

c.

CCDOC shall fill the 210 additional correctional officer slots provided for in provision

33.a; fill the 285 correctional officer vacancies that existed at the Facility as of July 17,

2009; and fill any correctional officer vacancies coming into existence after that date in the

following manner:

i.

By December 31, 2010, CCDOC shall hire, train, and put on duty at the

Facility at least 448 [381] newly qualified correctional officers (in addition to those on duty

as of December 31, 2009).

ii.

By March 30, 2011, CCDOC shall hire, train, and put on duty at the Facility at

least 178 [107] newly qualified correctional officers (in addition to those on duty as of

December 31, 2010).

April 2015 Compliance Status: Substantial Compliance.

Status Update: Remains in substantial compliance,

Monitor’s Assessment: See 33.a.

Monitor’s Recommendations: See 33. a.

d.

The parties agree that for 30 months following the effective date of this Agreed

Order, Cook County and CCDOC shall not be required to provide additional correctional

officer staffing and supervision at the Facility beyond that which is necessary to ensure that

correctional officer staffing and supervision are sufficient to achieve the purposes set out in

the introductory paragraph of provision 33 and to comply with provisions 33.a-c above.

April 2015 Compliance Status: Substantial Compliance

Status Update: See 33.b.

Monitor’s Assessment: See 33.b.

Monitor’s Recommendations: See 33.b.

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e.

Within 30 months of the effective date of this Agreed Order, the CCDOC Monitor shall

assess and make a recommendation on whether the correctional officer staffing and

supervision levels are appropriate to adequately supervise inmates at the Facility, in

accordance with generally accepted correctional standards. If the CCDOC Monitor

determines that staffing is inadequate, the CCDOC Monitor will make a recommendation

regarding the appropriate number of correctional officer staff. If the parties do not accept

the CCDOC Monitor’s staffing recommendation, CCDOC and Cook County shall agree to an

independent, comprehensive study to determine the appropriate correctional officer staffing

and supervision. The parties agree that the results of this staffing study shall provide

guidance as to the sufficient number of qualified correctional officers necessary to operate

the Facility safely and to carry out the requirements of this Agreed Order.

April 2015 Compliance Status: Substantial compliance

Status Update: See 33.b.

Monitor’s Assessment:

See 33.b.

Monitor’s Recommendation: See 33.b.

f.

If the staffing study requires additional correctional officers, Cook County shall

allocate funds sufficient to maintain correctional officer staffing levels necessary to carry out

the requirements of this Agreed Order and to allow for the safe operation of the Facility,

consistent with generally accepted correctional standards.

April 2015 Compliance Status: Substantial compliance

Status Update: See 33.b.

Monitor’s Assessment: See 33.b.

Monitor’s Recommendation: See 33.b.

g.

If the staffing study requires additional correctional officers, and consistent with

Cook County’s allocation of funds for security staffing, CCDOC shall hire and train sufficient

number of qualified correctional officers and other staff to carry out the requirements of this

Agreed Order and to allow for the safe operation of the Facility, consistent with generally

accepted correctional standards, including:

1. Investigative staffing sufficient to meet the internal investigation responsibilities

outlined in this Agreed Order;

2. Correctional officer staffing sufficient to provide inmates requiring treatment with

adequate access to appropriate medical and mental health care by providing timely

movement of inmates to medical units, transport of inmates who have been referred

for outside specialty care, and escort, if necessary, to Qualified Medical and Mental

Health Staff on housing units; and

3. Qualified staff sufficient to monitor security cameras in real time and allow for

supervisory viewing and retrieving at any time.

April 2015 Compliance Status: Substantial compliance.

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Status Update: The Inspector General is evaluating staffing needs of a revised investigative function. In the interim, this paragraph remains in substantial compliance.

Monitor’s Assessment: Based on the Inspector General’s review of staffing, the CCDOC should work expeditiously to fill those positions with qualified and experienced personnel.

Monitor’s Recommendation: Complete the review process; fill positions identified to enhance operations and functions..

h.

CCDOC shall maintain a written staffing plan that requires sufficient staffing to carry

out the requirements of this Agreed Order and to allow for the safe operation of the Facility,

consistent with generally accepted correctional standards.

April 2015 Compliance Status: Substantial compliance

Status Update: See 33.b.

Monitor’s Assessment: See 33.b.

Monitor’s Recommendation: See 33.b.

i.

Absent exigent circumstances, CCDOC shall maintain a practice that does not allow

for scheduled, planned, or expected cross-watching (a CCDOC practice of allowing one

correctional officer to simultaneously supervise two housing units from the control center of

one of the units) at any time on all maximum security and Special Management Units, and

during first and second shifts throughout the Facility.

April 2015 Compliance Status: Substantial Compliance

Status Update: CCDOC reports no deficiencies.

Monitor’s Assessment: I have received no complaints from employees and/or unions regarding cross watching. Division 5 has been closed for some time, and this had been the source of complaints.

Monitor’s Recommendation: None at this time

j.

CCDOC may permit cross watching on third shift in housing units that are not

maximum security or Special Management Units only if the Monitor does not object after

consultation and review. The Monitor’s review of the appropriateness of third-shift cross-

watching on a particular housing unit shall be guided by the sufficiency of sightlines

between the units being cross-watched, the adequacy of video and/or audio technologies in

place, and/or other factors that bear on the safety and security of inmates and staff. If the

Monitor later objects to any cross-watching that is in effect because of the Monitor’s

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concerns that cross-watching on a particular housing unit presents an undue risk to the safety and security of inmates and staff, CCDOC shall immediately cease such crosswatching. CCDOC may renew cross-watching on that unit again if, after further consultation with and review by the Monitor, the Monitor does not object to such renewal. Although cross-watching is permitted under the limited circumstances described herein, CCDOC will work to eliminate the practice at the Facility.
April 2015 Compliance Status: Substantial Compliance
Status Update: See 33.i.
Monitor’s Assessment: See 33.i.
Monitor’s Recommendation: See 33.i.
34. Incidents and Referrals
April 2015 - There are seven (7) paragraphs in the Agreed Order that address incidents and referrals. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • reviewed samples of incident reports; • review of summary reports regarding inmate/inmate violence; • review of weekly reports of incidents and follow-up with CCDOC concerning questions; • examined the current policy; and • reviewed the existing lesson plans for pre-service training.
Regarding paragraph 34.d., there is at least a two-step system for identifying incidents requiring further review – the work of the Use of Force Review Unit and the grievance process. Additionally, CCDOC is updating the process by there is weekly management review of incidents, trends, action plans, etc. (Jail Management Meeting draft General Order dated 4/1/2015). Implementation of this revised General Order will be assessed during the next tour. The Cook County Sheriff’s Office also has a relatively new Office of Research that is providing analysis of agency data to provide the basis for data driven decisions. For example, the Office is even engaged in consideration of a prediction model for use of force to further work to prevent inappropriate or excessive uses of force. This approach – both the existence of an Office of Research and modeling is very cutting-age for a jail system.

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There is a new jail management and recordkeeping system as of October 2014, CCOMS replacing IMACs. This new system was the capacity to go beyond what is required in the Agreed Order to provide a wide-range of data, and the ability to collect and analyze information almost real-time.
I reviewed evidence that indicates OPR investigations are being initiated through inmate grievances, and that that inmate grievances are forwarded to OPR. Additionally, OPR provided information regarding referrals of cases involving possible criminal misconduct to the prosecutor. For CY 2014 and through the first quarter of 2015, the Inspector General reports that eight cases involving allegations of excessive force were presented to and declined by the prosecutor; and two cases were presented which are pending. Cases were also presented involving employee introduction of contraband, custodial sexual misconduct, theft, and filing flaw police reports. For the eight employees referred for use of excessive force and declined: one is pending command channel review (discipline); four are pending Merit Board action; one was exonerated by the Merit Board; and two are pending disciplinary committee review. [See also 35. Investigations.]
35. Investigations - Investigations at the Facility are conducted by independent departments under the Cook County Sheriff’s Office, including the Office of Professional Review, the Criminal Investigations Unit, and the Sheriff’s Police Department. The Cook County Sheriff will assume responsibility for requiring these investigatory units to comply with the relevant provisions of this Agreed Order.
There are seven (7) paragraphs in the Agreed Order which investigations. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • Met with Inspector General and OPR leadership; • Reviewed the organizational structure and assignment of staff; • Reviewed a limited number of case files and sample documents for different investigative milestones; • Examined data for the system including assigned cases and weekly reports; • Reviewed staffing; • Reviewed employee training; and • Examined cases referred for prosecution.
With every monitoring tour I find that the level of attention to detail and professionalism grows within the Cook County Sheriff’s Office’s investigative

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functions. My only concerns are: that the staffing continue to be a priority, and that the employee discipline systems now in place are appropriately accelerated to insure swifter sanctions for employee misconduct in cases where discipline is indicated.
36. Inmate Disciplinary Process
April 2015 - There are six (6) paragraphs in the Agreed Order that address the inmate disciplinary process. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • met with the staff assigned to manage the inmate disciplinary procedures; • spoke with inmates about their experiences with the disciplinary process; and • reviewed the data provided regarding the process.
In reviewing the data I requested additional information regarding inmate disciplinary write-ups that were invalid/expired (11% of the total charges for the first three months of 2015, up from 5% for the previous calendar year). CCDOC’s review indicated that the spike in invalid reports was due to several circumstances in which the entire living area received a discipline infraction rather than the individual inmate(s) involved in the violation (in this case reported as “compliance violations” such as obstruction of air vents, washing clothes in a cell, or possession of a clothes line.) CCDOC reported with the implementation of the new jail records system in October 2014 (CCOMS) the number of expired discipline reports are decreasing. CCDOC reports that the matter that resulted in the spike in invalid reports in February will be addressed through training.
Inmates did not report any issues regarding the inmate disciplinary process. CCDOC continues to review civilian hearing officers.
For the calendar year 2014, CCDOC reports where were 11,038 inmate violations written for serious (300+violations). Ninety-one percent of the total reports written were valid. Of those. 80% of the inmates were found guilty, and 20% not guilty. Less than 10% of reports were expired, invalid, or the inmate was no longer in custody. Data supplied by the Inmate Disciplinary Unit also includes reviews done by Cermak’s mental health staff for inmates on the mental health caseload pending disciplinary action (N=408). For the first quarter of 2015, 2,535 inmate disciplinary reports

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have been written (annualized 10,140). Of those, 12% were expired, invalid, or the inmate discharged; 87% of inmates were found guilty of charges, and 13% not guilty.

37. Classification

a.

CCDOC shall maintain policies and procedures for an appropriate, objective

classification system that separates inmates in housing units by classification levels in order

to protect inmates from unreasonable risk of harm. The system shall include consideration

of an inmate’s security level, severity of current charge, types of prior commitments, suicide

risk, history of escape attempts, history of violence, and special needs. CCDOC shall use

best efforts to anticipate periods of unusual intake volume and schedule sufficient

classification staff to timely classify inmates.

April 2015 Compliance Status: Substantial Compliance

Status Update: The revised classification was implemented on October 26, 2014. The new jail management information system (October 2014), Cook County Offender Management System (CCOM)s manages the classification processes.

Monitor’s Assessment: It was anticipated that the updated/revised inmate classification system would result in fewer inmates classified as “maximum” custody. Through March 29, 2015, the trend is as was anticipated, with a decrease in the number of inmate classified as maximum custody and an increase in inmates classified as medium and minimum. A slight downward trend is also noticed in the classifications of female inmates.

Monitor’s Recommendations: Prepare for the completion of a validation study in the fall of 2015. Assure that moves of inmates completing their sentences in disciplinary segregation are reported to the Classification unit.

b.

CCDOC shall ensure that classification staff have sufficient access to current

information regarding cell availability on each division.

April 2015 Compliance Status: Substantial compliance.

Status Update: CCOMS will provide the data.

Monitor’s Assessment: System has been implemented.

Monitor’s Recommendation: See 37.a.

c.

CCDOC shall include information on each inmate’s assignment to the Special

Incarceration Unit “level system” at the Facility in the new Jail Management System,

starting with the date the new Jail Management System becomes operational.

Report # 10 May 27, 2015

32

April 2015 Compliance Status: Substantial compliance.

Status Update: Remains in substantial compliance. CCOMS provides the data.

Monitor’s Assessment: Nothing further at this time.

Monitor’s Recommendation: Continue the monitoring of inmates in special incarceration and protective custody

d.

CCDOC shall provide training and access to all correctional officer supervisors on the

full capabilities of the new Jail Management System’s classification and inmate tracking

system (or any replacement system).

April 2015 Compliance Status: Substantial Compliance.

Status Update: CCOMS implemented on 10/26/14.

Monitor’s Assessment: Nothing further at this time.

Monitor’s Recommendation: NA

e.

CCDOC shall provide ongoing internal and external review and validation of the

inmate classification system to ensure its reliability and objectivity.

April 2015 Compliance Status: Substantial compliance.

Status Update: Pending system being operational for one year.

Monitor’s Assessment: At least a preliminary validation of the new system is anticipated for review at the time of the next tour. This validation should be able to document that the new system has resulted in fewer indicators of disorder – inmate/inmate fights, uses of force, etc. because better information has been used to house inmates.

Monitor’s Recommendation: CCDOC should be prepared at the time of the next monitor’s tour to share the preliminary validation data.

38. Inmate Grievance Process

April 2015 - There are four (4) paragraphs in the Agreed Order that address the inmate grievance process. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work

Report # 10 May 27, 2015

33

since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • met with the Inmate Service Department staff who oversee and manage the inmate grievance process; • reviewed the CCDOC grievance data; • interviewed inmates regarding the grievance process; • reviewed grievance forms; • read the “FAQs” available to assist inmates developed by the grievance unit; • read the review by counsel of the analysis of a sample of grievance responses (quality control); • reviewed Cermak’s grievance data; • reviewed the number of grievances referred for allegations of misconduct to OPR;11 • reviewed housing unit logs to assure CRWs have signed in; and • assessed the “early warning” system that the grievance staff maintains.
One of the more evident and important accomplishments for CCDOC during the course of the monitoring has been the creation and maintenance of a credible inmate grievance process. I interviewed close to 200 inmates in three different divisions and virtually no inmate had an issue with getting a grievance form, turning in a grievance form, or receiving responses. While not all inmates were happy with the response they received, they are receiving responses. I was able to view many, many pages of grievances shown to me by the inmate’s with whom I spoke.
Data is maintained, analyzed and reviewed with the CCDOC leadership team regarding inmate grievances. More than 7,500 grievances were received and processed in 2014, and more than 1,700 for the first three months of 2015. As would be expected, medical grievances accounted for 58% of grievances in 2014, and 44% of grievances for the first quarter of this calendar year. The next largest category of inmate grievances was: 15% staff misconduct (non-physical) in 2014 and year to date in 2015.
Although not required by the Agreed Order, the grievance section also monitors staff actions alleged by an inmate to determine any needed changes in staff counseling, training, and/or policy. Inmate Services

11 OPR data indicates for 2014: 100 grievances were referred regarding allegations of excessive force, and 43 inmate grievance for failure to protect. For the first quarter of 2015; 2015 65 grievances alleging excessive force and 13 alleging failure to protect have been forwarded to
OPR.

Report # 10 May 27, 2015

34

reports that since the system began 64 staff members have been identified in 3 or more grievances as benefiting from counseling regarding their actions that may have resulted in an inmate grievance.
Additionally, CCDOC counsel reviews a sample of grievance each month and produces an audit report regarding the grievances reviewed. For example, the audit may note that the process and response was timely and acceptable, or that the response was not on point, or that time limit was not adhered to. The audit also addresses any grievance appeal. I reviewed the audit findings for January/February 2015. These two systems are innovative and assure that the inmate grievance process is reviewed from various perspectives not only to address inmate issues, but emerging staff/supervisor issues as well.
Since November 2014 CCDOC is also tracking “emergency grievances” and the outcomes. This is another inmate safety and quality control issue.
A previous concern about CRW staffing and their presence in the housing units seems to have been adequately addressed. There are several vacancies in the CRW positions that are being recruited/processed at this time. In the absence of CRWs the divisional superintendents know what to do to retrieve grievances. Staffing has been addressed also by dealing with paperwork flow.
My review of housing unit logs indicates that the CRWs are signing in and out of units, documenting their presence. Inmates told me that they had access to the CRW and I heard no complaints about access to either the grievance process or the CRW – and this included Division IX inmates. I identified only one instance where a non-English speaker needed assistance (Division I) and a Spanish speaking officer quickly arrived. Other LEP inmates I spoke with in Division IX were able to use the grievance process.
Another innovation is the creation of “FAQs” derived from inmates’ grievances and designed to provide basic information for officers and inmates. It is anticipated that there may be a drop in the number of grievances as officers can give consistent answers and inmates have answers to frequently asked questions. The next initiative for the Inmate Services Department is to work with the small number of inmates (N=102) who are responsible for 28% of the grievances.
The focus on grievances by the CCDOC leadership accentuates the importance of superintendents knowing their numbers of grievances, the issues, and urging them to work on the underlying conditions.

Report # 10 May 27, 2015

35

An area that remains to be resolved is the medical grievance issue. While on-site I was provided with a grievance report from Cermak for November 2014– February 2015. The information had not previously been seen by CCDOC’s Inmate Services Department, and the numbers presented were not consistent with CCDOC’s data. The definitions used by Cermak also were unclear. As a result, CCODC will work with Cermak to assure a unified procedure and recordkeeping for medical/mental health/ dental data.
I commend the Inmate Services Department for their incredibly hard work and single-minded determination to meet and exceed the requirements of the Agreed Order. Inmate Services has also developed several innovative procedures that should be shared with jails nationally.
39. Access to Information
April 2015 - There are two (2) paragraphs in the Agreed Order that address access to information. All of these paragraphs have remained in substantial compliance for 18 months. While not addressing each paragraph individually, the following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • reviewed the current inmate handbook in English/Spanish.
My recommendation is to assure that the inmate handbooks are updated as needed, and that a date be added to each revised production to assure version control. I also recommend that CCDOC continue to implement alternatives to distributing written handbooks to inmates, including but not limited to use of kiosks, single laminated copies at officer workstations, and periodic inmate housing unit briefings by CRWs.
40. CCDOC shall provide training and supervision to all correctional officers and supervisors sufficient to implement the provisions of this Agreed Order.
April 2015 - There is one (1) paragraph in the Agreed Order that address training. This paragraph has remained in substantial compliance for 18 months. The following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • reviewed the in-service training schedule.
I will review training information and documentation during the next tour.

Report # 10 May 27, 2015

36

41. Inter-Agency Agreement
April 2015 - There is one (1) paragraph in the Agreed Order that addresses the Inter-Agency Agreement. This paragraph has remained in substantial compliance for 18 months. The following is a summary of CCDOC’s work since the tour of September 2014.
In assessing CCDOC’s on-going compliance for these requirements I: • reviewed minutes of meeting.
I urge the parties to continue to meet regularly and produce solutions to issues. This practice should continue long after compliance with the Agreed Order is achieved.
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily available, safely secured, suicide cut-down tools. Coordinate with Dr. Metzner
April 2015 - There is one (1) paragraph in the Agreed Order that addresses the availability of cut-down tools. According to CCDOC the tool was used 95 times in 2014 and from 1/1/15 – 5/5/15, 45 times.
In assessing CCDOC’s on-going compliance for these requirements I: • Reports by incident number for 2014 and 2015 YTD.
I recommend that CCDOC analyze the data by housing unit, mental health status of the inmate, significance of the attempt, and training and/or policy implications, if any.

Report # 10 May 27, 2015

37

 
 NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION


UNITED STATES OF AMERICA,

Plaintiff,
V.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK'COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants,

No. 10 C 2946 Judge Virginia Kendall

Monitor Harry E. Grenawitzke’s Report No. 10 Fire, Life Safety, and Environmental Health April 28, 2015

Harry E. Grenawitzke, RS, MPH, DAAS Grenawitzke & Associates, LLC 50 Sheridan Drive Monroe, MI 48162
E-mail: harry.grenawitzke@gmail.com
Page 1 of 58

Executive Summary
April 13-16, 2015
The tenth tour of CCDOC focused primarily on touring divisions and limited meeting with staff. The purpose was to observe evidence of compliance and progress with the provisions of the Consent Agreement between the US Department of Justice Civil Rights Division and Cook County. I monitored implementation of policies and procedures established to address the provisions for Cook County Department of Corrections (CCDOC), Department of Facilities Management (DFM), and Cermak Medical and Mental Health Facilities (Cermak). As part of the tours I interviewed inmates in all divisions visited, correction staff, supervisors, division superintendents, Support Services staff, maintenance personnel, and leadership and staff of Cermak. The results of the tours and responses from conversations provide the information included in this report.
As of the completion of this tour, all 39 provisions of the Consent Agreement are now deemed to be “substantially compliant/” ongratulations/ This could not have happened without the dedicated commitment and leadership displayed by management and staff of all three entities. First and foremost I want to extend my appreciation to all the leadership and staff of DFM, CCDOC, and Cermak for their hospitality and generosity with their time and support. The cooperation and willingness of Bilqis Jacob-El of DFM, Cara Smith of CCDOC, Dr. John Raba, and Peter Daniels of Cermak to share their ideas and suggestions for improvement are clearly recognized. I also want to commend Sheriff Thomas Dart for his leadership, his commitment to continually improve the conditions of confinement at CCDOC and his dedication to his staff. His leadership as demonstrated by the many initiatives has clearly changed the perceptions of CCDOC. He continues to earn my respect and that of his leadership team. I also want to recognize Bilqis Jacob-El of DFM and Dr. John Raba and Peter Daniels of Cermak for their commitment to continually improve DFM and Cermak respectfully.
Page 2 of 58

Specifically the last two provisions G/83b and G/ 83i are now “substantially compliant. There are 35 of 39 provisions that have continued to demonstrate “substantial compliance for a minimum of 18 months. The four that have not are 83.b, 83.i, 84.b, and 84.c. I expect that as of the next tour the last two provisions (84.b and 84.c) will be added to those that have demonstrated sustainability. Significant progress and improvements highlighted in the report include:
1. Continued reduction of detainees to less than 9000.
2. Continued improvement in sanitation in most of the divisions;
3. Implementations of the policy to assure detainees have ready access to hygiene items.
4. Divisions IV and V continue to be vacant and female detainees are in Division III;
5. Complete reconstruction of the showers in Division I by DFM;
6. Ongoing progress in the DFM building initiative program within Division VI with removal of floor tiles completed for upper and lower tiers 1D;
7. Completing emergency lighting on the catwalks of Division I Tiers, C-3, C4, d-3, D-4, and F-1;
8. Replacing of leaking slop sinks for Division II Dorm 3 H, F, and DD;
9. Shower Unit B-1 in Division III was refurbished;
10.Continued significant reduction in the maintenance backlog for all work orders, but specifically plumbing and electrical;
11. Significant improvement in organization and sanitation throughout the Cermak infirmary and clinics;
Recognizing the progress identified above, there are also some issues that remain or have not demonstrated improvement or in some cases have regressed and now require management attention from
Page 3 of 58

interagency management and/or respective organization before the next tour. Among these are:
1. The need to continually work to improve utilization of the Central Laundry for detainee’s personal clothing especially in Divisions II, VI,IX, and XI;
2. Assuring that all division superintendents, commanders and supervisors recognize their health, safety and security along with the inmates to which they are assigned to protect to assure that housing units are maintained clean, free of excess food, elimination of inmate ropes, fire hazards, and in good repair
3. CCDOC needs to obtain an adequate amount of power washers to maintain showers in Division VIII clean and free of soap scum build-up. I suggest at least one power washer per floor with one reserve. Also because that building is not equipped with adequate floor drains, CCDOC needs to increase the number of wet vacuums available to rapidly remove water from inmate caused floods in the dormitories and cells.
4. Cermak needs acquire enough hospital beds for inmate patients and eliminate the need for “boats”/ !s identified in the previous report, assure that as specified in the American Correction Association Performance Based Standards states that Multiple –occupancy rooms/cells that house between two and 64 occupants provide at least 35 square feet of unencumbered space where confinement exceeds ten hours per day. There are far too many inmates housed in dormitories within Cermak for the amount of space available.
5. CCDOC, through its fire safety committee assure that fire drills are effectively documented and a comprehensive review of the reports is completed to identify gaps in either training or procedures. On this tour fire drill report formats are inconsistent, most make no
Page 4 of 58

recommendations for improvement and there is no evidence of a formal review process. As always I remain available to assist in helping staff understand the need for and review ideas to solve them.
Sincerely,
Harry E. Grenawitzke, RS, MPH, DAAS Monitor for Fire, Life Safety and Environmental Health

Summary May 5, 2015

Page 5 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

C. C. 53 C. 53e
C. 53f
F. F. 71

Medical Care

Treatment and Management of Communicable Disease

Cermak shall ensure that the negative pressure and ventilation

3/11 9/10

systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in- 8/11 7/12

use. Cermak shall document results of such testing.

12/11

2/13

9/13

3/14

10/14

4/15

Cermak shall notify DFM, in a timely manner, of routine and

7/12 3/11

9/10

emergency maintenance needs, including plumbing, lighting and ventilation problems.

2/13 8/11

9/13 12/11

3/14

10/14

4/15

Fire and Life Safety

CCDOC and DFM shall work together to develop and implement a fire safety program and ensure compliance is appropriately documented. The initial Fire Safety Plan shall be approved by the fire prevention authority having jurisdiction. The Fire Safety Plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and

12/11 9/10 7/12 3/11 2/13 8/11 9/13
Page 6 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

emergency procedures shall be standardized across divisions, to the

extent possible given differences in physical plant and security

levels.

3/14

10/14

4/15

F. 72 CCDOC shall develop and implement an evacuation plan for inmates 12/11 Not

and staff and ensure that comprehensive fire drills are conducted every three months on each shift. CCDOC shall document these

7/12

Assessed
9/10

drills, including start and stop times and the number and location of 2/13 3/11 inmates who were moved as part of the drills.

9/13 8/11

3/14

10/14

4/15

F. 73 DFM shall ensure that the Facility has adequate fire and life safety 7/12 9/10

equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable

2/13 3/11

fire codes. Maintenance and storage areas shall be equipped with 9/13 8/11 sprinklers or fire resistant enclosures in accordance with City of

Chicago Fire Code (13-76-010).

3/14 12/11

10/14 4/15

F. 74 DFM shall ensure that all fire and life safety equipment is properly 3/11 9/10

maintained and routinely inspected. DFM shall develop and

implement a program related to the testing, maintenance and

8/11

inspection of the Life Safety Equipment.

12/11

7/12

Page 7 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

2/13

9/13

3/14

10/14

4/15

F. 75 CCDOC shall continue to ensure that emergency keys are

2/13 9/10

appropriately marked and identifiable by touch and consistently stored in a quickly accessible location, and that staff are adequately 9/13 3/11

trained in use of the emergency keys.

3/14 8/11

10/14 12/11 4/15
7/12

F. 76 CCDOC shall ensure that staff are able to manually unlock all doors 2/13 9/10

(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 9/13 3/11

power outage or smoke buildup where visual examination of keys is 3/14 8/11 generally impossible. CCDOC shall conduct and document random

audits to test staff proficiency in performing this task on all shifts, a 10/14 12/11

minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall

4/15 7/12

communicate with DFM via the Work Order System regarding lock-

related issues and maintenance.

F. 77 DFM shall develop and implement an annual preventative

3/11 Not

maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking

Assessed
8/11 9/10

mechanisms to ensure these devices function properly in the event 12/11 of an emergency.

7/12

2/13

Page 8 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

9/13

3/14

10/14 4/15

F. 78 CCDOC shall implement competency-based testing for staff regarding fire and emergency procedures.

8/11 12/11

Not assessed
9/10

7/12 X3/11

2/13

9/13

3/14

10/14 4/15

F. 79 CCDOC shall promptly notify DFM of all electrical hazards, including 7/12 9/10

maintenance and repair of electrical outlets, devices, and exposed

electrical wires.

2/13 3/11

9/13 8/11

3/14 12/11

10/14 4/15

F. 80 DFM shall promptly repair all known electrical hazards, including

3/11 9/10

maintenance and repair of electrical outlets, devices, and exposed

electrical wires and will document repairs by the Work Order

8/11

System.

12/11

7/12

Page 9 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

F. 81
F. 82
G G. 83 G. 83a

2/13

9/13

3/14

10/14 4/15

CCDOC shall ensure that combustibles are controlled and eliminate 9/13 3/11 9/10

hi8ghly flammable materials throughout the facility and inmate living areas (e.g., inmates ‘use of paper bags as trash receptacles,

3/14 8/11

ripped fire-retardant mattress covers, improvised cell light covers, blankets on cell floors, and improperly stored and labeled flammable liquids and other chemicals).

10/14 12/11 4/15
7/12

2/13

CCDOC 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.

7/12 2/13 9/13 3/14 10/14 4/15

Not Assessed
9/10 3/11 8/11

SANITATION AND ENVIRONMENTAL CONDITIONS

Sanitation and Maintenance of Facilities

DFM shall maintain an adequate written staffing plan and sufficient 8/11 9/10 staffing levels to provide for adequate maintenance of the Facility.
12/11 3/11

7/12

2/13

Page 10 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83b G.83c

9/13

4/14

10/14 4/15

CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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.

4/15

9/10 3/11 8/11 12/11 7/12

2/13

9/13

3/14

10/14

DFM shall implement a preventive maintenance plan to respond to 3/11 9/10

routine and emergency maintenance needs, including ensuring that

shower, toilet, and sink units are adequately maintained and

8/11

installed.

2/11

7/12

2/13

9/13

3/14

10/14 4/15

Page 11 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83d CCDOC shall notify DFM, in a timely manner, of routine and

7/12 8/11

9/10

emergency maintenance needs, including plumbing, lighting, and

ventilation problems.

2/13 12/11 3/11

9/13

3/14

10/14

4/15

G.83e

DFM shall ensure adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on and annual basis for non-automated systems.

3/11 9/10 12/11 7/12 2/13

9/13

3/14

10/14

4/15

G. 83f

CCDOC shall notify DFM of any visible obstructions to the ventilation system.

7/12 3/11

9/10

2/13 8/11

9/13 12/11

3/14

10/14

4/15

G. 83g Cook County shall ensure adequate lighting in all inmate housing 2/13 9/10

Page 12 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83h G. 83i
G. 83j

and work areas.

9/13 3/11

3/14 8/11

10/14 12/11 4/15
7/12

CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.

2/13 9/10 9/13 3/11 3/14 8/11 10/14 X12/11

4/15 X 7/12

CCDOC shall ensure that all inmates have access to needed hygiene 4/15 supplies.

Not Assessed
9/10 or 3/11

8/11

12/11

7/12

2/13

9/13

3/14

10/14

CCDOC shall develop and implement policies and procedures for

2/13 Not

cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction

9/13

Assessed
9/10

standards. CCDOC shall ensure that any inmate or staff utilized to

Page 13 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

clean a biohazardous area are properly trained in universal precautions, are outfitted with protective materials, and receive proper supervision when cleaning a biohazardous area.

3/14 10/14 3/11 4/15 8/11
12/11 7/12

G. 83k DFM shall develop a policy on hazardous materials, in accordance 7/12 8/11

9/10

with generally accepted correctional standards, and insure that all

DFM staff is properly trained on the procedure.

2/13 12/11 3/11

9/13

3/14

10/14

4/15

G. 83l

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

8/11 12/11

Not Assessed
9/10

7/12 3/11

2/13

9/13

3/14

10/14

4/15

G. 83m CCDOC shall inspect and replace as often as needed all frayed and 8/11 3/11

9/10

cracked mattresses. CCDOC shall destroy any mattress that cannot

Page 14 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83n

be sanitized sufficiently to kill any possible bacteria. CCDOC shall 2/11 ensure that mattresses are properly sanitized between uses.
7/12

2/13

9/13

10/14

4/15

CCDOC shall ensure adequate control and observation of all housing 8/11 9/10

units, including distribution and collection of razors and cleaning supplies. All cleaning tools and hazardous chemical shall be

12/11 3/11

removed from housing areas after use.

7/12

2/13

9/13

3/14

10/14

4/15

G. 83o

CCDOC shall ensure that Facility sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.

12/11 9/10 7/12 3/11 2/13 8/11 9/13 3/14 10/14

Page 15 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

4/15

G. 84 Sanitary Laundry Procedures

G. 84a

CCDOC shall develop and implement policies and procedures for

8/11 9/10

laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted

12/11 3/11

correctional standards. To limit the spread of communicable

7/12

disease, CCDOC shall ensure that clothing and linens returned from

off-site laundry facility are clean, sanitized, and dry.

2/13

9/13

3/14

10/14

4/15

G. 84b CCDOC shall ensure that inmates are provided adequate clean

3/14 3/11 9/10

clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange

10/14 8/11

schedule provides consistent distribution and pickup service to all housing areas.

4/15 12/11

7/12

2/13

9/13

G. 84c CCDOC shall train staff and educate inmates regarding laundry sanitation policies.

3/14 8/11 9/10 10/14 12/11 3/11

4/15 7/12

2/13

9/13

Page 16 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 84d G. 84e G. 85

CCDOC 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.

12/11 9/10 7/12 3/11 2/13 8/11

9/13

3/14

10/14

4/15

CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
(* In the Monitor Report #V dated July 20, 2012; this provision was inadvertently recorded “substantial compliance/” The provision should have been recorded “partial compliance/”)

9/13 9/10 3/14 3/11 10/14 8/11 4/15 12/11
7/12*

2/13

Food Service

G. 85a G. 85b

CCDOC shall ensure that all food service at the Facility is operated in 9/13 3/11 9/10

a safe and hygienic manner and that foods are served and maintained at safe temperatures.

3/14 8/11

10/14 12/11

4/15 7/12

2/13

CCDOC shall ensure that all food service staff, including inmate

7/12

staff, must be trained in food service operations, safe food handling

9/10
Page 17 of 58

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 85c G. 85d G. 85e

procedures, and appropriate sanitation.

2/13 3/11

9/13 8/11

3/14 12/11

10/14

4/15

CCDOC shall ensure that the Central Kitchen and Division XI kitchen 2/13

are staffed with a sufficient number of appropriately supervised

and trained personnel.

9/13

3/14

9/10 3/11 8/11

10/14 12/11

4/15 7/12

CCDOC shall ensure that dishes and utensils, food preparation and 2/13 9/10

storage areas, and vehicles and containers used to transport food

are appropriately cleaned and sanitized.

9/13 3/11

3/14 8/11

10/14 12/11

4/15 7/12

CCDOC shall check and record, on a regular basis, the temperatures 7/12 9/10

in the refrigerators, coolers, walk-in-refrigerators, the dishwasher water, and all other kitchen equipment with temperature monitors 2/13 3/11

to ensure proper maintenance of food service equipment.

9/13 8/11

3/14 12/11

10/14

4/15

Page 18 of 58

STATUS REPORT
DATE OF STATUS REPORT: 10/17/14
PROVISION: C. MEDICAL CARE
53. Treatment and Management of Communicable Disease
e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Since July, 2012 the Department of Facilities Management (DFM) continues to monitor and record the results of the negative pressure testing for the 18 isolation cells located on the third floor (3-E) of Cermak, along with the enunciator panel once each shift. Work orders are submitted and appropriate repairs made when monitoring demonstrates non-compliance. Occupational and Environmental Hygiene Services at the Great Lakes Center for Occupational and Environmental Safety and Health at the University of Illinois, Chicago, conducts a full testing of the ventilation system annually. Copies of those reports are provided to the Chief Medical Officer of Cermak.
Monitor’s !ssessment: There is no change from the previous report. The pressure monitoring by DFM is included in their Preventative Maintenance Schedule. The checks are documented in logs maintained by DFM. On this tour, only one isolation cell was occupied. However, it was not being used for a medical issue requiring a negative pressure cell. This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
PROVISION: C. MEDICAL CARE
53. Treatment and Management of Communicable Disease
f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
ermak continues to submit work orders through the “Facility Wizard” work order system utilized by Department of Facilities Management for all emergency and routine repairs as well
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as scheduled maintenance/ ermak’s Environmental Services Director or !ssistant Director of Plant Operations/Environmental Services submits all work order requests to DFM electronically. They have the capability at any time to monitor the status of work order. The interface for “Facility Wizard” system that allows ermak to access information on DFM work order repairs continues to operate effectively since its inception in April, 2012. Cermak’s Environmental Services Director has the ability to monitor progress for all outstanding work orders through the online database.
Monitor’s !ssessment:
ermak’s Environmental Services Director submits many of the work orders/ !s a result of the previous tour Cermak management staff, nursing and compliance staff, along with CCDOC Sanitarians and DFM initiated bi-weekly inspections throughout the infirmary and the division specific dispensaries. Those inspections have worked to effectively identify issues requiring DFM maintenance. A review of work orders submitted also demonstrated that DFM staff has initiated work orders as a result of their continual work there. Again on this tour I noted nonfunctioning emergency call lights in 3-E. This has been an ongoing issue for at least the past three tours. Prior to the tour DFM decided to initiate a capital project to replace the aging emergency call lighting system throughout the Cermak infirmary. This should resolve this issue. Cermak management staff needs to continue the bi-weekly inspection tours of the infirmary and dispensaries until they are assured that ongoing maintenance issues are quickly addressed. The progress made since the previous tour is significant and the provision will remain in substantial compliance. If, however, on the next tour, the corrective action is not completed, the compliance status will be moved to either partial or non-compliance.
Monitor’s Recommendations:
1. Cermak needs to establish the Cermak infirmary and dispensary inspection program as a formal Cermak policy. The policy should include a process to formally document the results of each inspection and include a method to assure not only correction, but corrective action of the cause of the issue.
2. Cermak management needs to develop a written procedure to require at least daily monitoring of the patient emergency call button system to assure that inmates assigned to housing in the medical and mental health tiers have the ability to alert staff in the event of an emergency.
3. As requested in the previous report, please provide me with the Cermak documented procedure as to how non-conformances identified during routine inspections will be addressed Cermak’s Environmental Services staff including a root cause analysis and the
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implementation and monitoring of “corrective action” that addresses the cause of the nonconformity, not just the correction.
PROVISION: F. FIRE AND LIFE SAFETY
71. CCDOC and DFM shall work together to develop and implement a fire safety program and ensure compliance is appropriately documented. The initial Fire Safety Plan shall be approved by the fire prevention authority having jurisdiction. The Fire Safety Plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and emergency procedures shall be standardized across divisions, to the extent possible given differences in physical plant and security levels.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Interagency Committee consisting of the Directors of CCDOC, DFM, and Cermak created the Fire Safety Committee (FSC) in August, 2010 They continue to meet monthly to review and assess the fire safety and prevention systems and make improvements to it. The program is documented in accordance with the provisions of the consent agreement. The Fire Safety committee consists of representatives from the Office of the Sheriff, Department of Corrections, Cermak Health Services, and the Department of Facilities Management/ Each division within DO has a documented “Fire Safety and Emergency Plan” which includes the procedure to follow in case of a fire and a detailed emergency evacuation procedure. These plans have been reviewed by the City of Chicago Fire Department. The Chicago Fire Department in correspondence dated Dec. 24, 2013 has accepted the CCDOC Fire Evacuation and Emergency plans and the General Orders as written. Further the City of Chicago fire inspectors completes an inspection of CCDOC annually. The 2015 inspection was completed January 68. They have found either full compliance with previously identified violations or that they were in the process of being corrected. Currently a fire prevention inspector from the Chicago Bureau of Fire Prevention visits the complex to provide advice to personnel on fire safety issues. Scheduled, unannounced fire drills are conducted regularly on all shifts for all divisions. When available, an inspector from the Fire Prevention Bureau, along with the responding fire station firefighters participates as part of their response training.
CCDOC, DFM, and Cermak issued the Interagency Directive, 64.5.30.0, effective date of August 22, 2011 that establishes the policy and procedures for Fire Safety Plans, fire emergency response, and evacuations within CCDOC. The Directive establishes the respective roles and responsibilities for CCDOC, Cermak, and DFM relating to Fire Safety Plans, emergencies and evacuations. CCDOC has a designated fire safety administrator and fire safety officer position and each division has designated trained safety officers assigned for each shift including weekends and holidays. Fire Safety Training is offered a minimum of twelve times per year for current Supervisors and Officers. In addition new recruits receive at the Sheriff’s Training Institute located in Moraine Valley Community College. These classes are taught by Deputy Director ook ounty Sheriff’s Office, Training Institute, who also chairs the
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interagency Fire Safety Committee. The Fire Safety Interagency Agreement requires divisional Safety Officers to conduct weekly fire safety inspections of all housing, administrative, medical clinics, storerooms, maintenance rooms, classrooms, and common areas within their respective divisions and that fire drills be conducted quarterly on each shift in all divisions. CCDOC General Order 24.11.1.0 was revised to require these inspections. General Order 24.11.1.1 was issued on October, 3, 2014
Monitor’s !ssessment:
Since its inception, I have continued to receive and review the summaries of the meetings of the Interagency Fire Safety Committee.
In reviewing the meeting summaries provided prior to this tour I noted that ermak’s representative continues to be a representative of Environmental Services. Cermak should consider one representative from Environmental Services and one management representative to assure that the committee considers the needs of medical and mental health inmates as it relates to fire safety and evacuation requirements. Cermak needs to be represented by a person with authority to make decisions on behalf of ermak’s patients, staff, both from a medical and security perspective/ The Interagency Directive continues to be in effect. Since October, 2011 drills continue to be conducted throughout the entire complex more frequently than required in the Interagency Directive. There is a post drill written report and formal review of every drill with participants and the fire safety committee. CCDOC develops the fire drill schedule for each division and the written drill report is reviewed by the Committee to identify additional training needs.
As a result of this tour I suggest that the Fire Safety Committee consider reviewing its role and establish a process with training to fully investigate the cause of all smoke and fire events to identify the ignition source, along with their review of drills, and inspection to make necessary changes to improve both policy and training As of this tour there has been a slight increase in both fire and smoke events apparently as a result of the temporary discontinuation of the use of microwaves due to equipment damage. In 2015, to date, the Fire Safety Committee conducted Safety Officer Training classes for 125 new or recertified safety officers.
While there will always be recommendations to continue improving the fire safety and prevention system, the provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. Continue the fire safety training for all correction officers. Assure that correction officers assigned to a specific division understand the fire safety plan for that division and are able to demonstrate through drills effective implementation of it during an emergency.
2. Assure that Cermak management is represented on the Interagency Fire Safety Committee that can contribute to assure both patients and staff issues are addressed.
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3. Complete the revision process for the Interagency Directive for Fire Safety, Fire Emergency, and Fire Evacuation 64.5.30.0 to assure that they reflect current operations, regulations, and practice. The review needs to be completed at least every two years in accordance with the consent agreement.
4. Continue the unannounced fire drills on all shifts as planned, along with the review of each drill completed by the CCDOC Safety Administrator. Document all corrective actions taken for any identified non-conformances. The Interagency Fire Safety Committee should also review quarterly results of fire drills and make adjustments to the Safety Plan and training as necessary.
72. CCDOC shall develop and implement an evacuation plan for inmates and staff and ensure that comprehensive fire drills are conducted every three months on each shift. CCDOC shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Based on the correspondence referenced in Provision 71 above, division specific Fire Safety and Emergency Plans that include detailed evacuation plans are complete and have been reviewed by the Chicago Fire Department. The Interagency Fire Safety Committee reviews these plans, along with the division safety officers to assure they remain current. The Fire Safety Committee has implemented a division specific fire evacuation and emergency key egress box training program to assure that when officers are assigned to a specific division, they are adequately trained in that division’s emergency egress key location, response and evacuation procedures.
CCDOC is currently conducts one fire drill per month on each shift that includes the movement of inmates for each division. Extinguishers are brought to the drill locations. While the consent agreement is not clear as to whether the drill frequency is for the entire complex or within each division, the Fire Safety ommittee’s intent is that all divisions are drilled 12 times annually over all three shifts/ Written reports are completed and reviewed for non-conformities and corrective action taken including retraining following the drills. This provision is substantially compliant.
Monitor’s !ssessment:
I did not witness any fire drills during the tour. However, following the tour, I asked and received copies of drills from each of the divisions. In reviewing those reports, it is clear that the policy of reviewing the drill results by the Fire Safety Committee is not occurring consistently. Further, the drills are not being documented consistently. For example, in Division XI, what was provided was just a list of drill dates on an unsigned report. There were no drill reports for any of the drills. More importantly in reviewing the drill reports provided from other divisions, with the exception of two recommendations from Division I asking recommending that drill frequency be increased to assure officers understand drill response, not one other report had any recommendations to improve policy, training , or response. On some of the reports that were handwritten, the recommendation section was typed “No recommendations”-
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suggesting that the form was pre-written. This is does not comply with the Interagency Policy nor the provision requirement of documenting drills. I will not change the provision of substantial compliance unless the next tour does not show corrective action.
Monitor’s Recommendations:
1. I am requesting the Fire Safety Committee to conduct an investigation into the fire drill policy lack of implementation, identify the root cause of why the policy is not being implemented as written, and a written corrective action plan to assure that the root cause is completed. I expect this report within 30 days of receiving the written report.
2. Continue fire drills on the monthly schedule for each shift and division with documentation that follows the agreed order. Maintain an updated record showing the last date any housing unit has conducted a fire drill to be able to demonstrate that drills are reasonable being spread throughout each Division.
3. Maintain and provide me with a list of dates and locations of all fire drills completed for 2015, and provide me a summary of the quarterly assessments from the Fire Safety Committee that include recommendations for improvements in the applicable policies, procedures and for both initial and refresher training prior to the December, 2015 tour.
4. Establish as part of the fire safety General Order a process to that all emergency flashlights are continually functioning and batteries fully charged.
73. DFM shall ensure that the Facility has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable fire codes. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures in accordance with City of Chicago Fire Code (13-76-010).
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Department of Facilities Management (DFM) has the responsibility to provide and maintain all fire and life safety equipment within the CCDOC complex. All housing areas, kitchens, maintenance facilities etc. are provided with an adequate number of functioning fire extinguishers, fire alarms and smoke detectors in accordance with the City of Chicago Fire Code. Testing and maintenance is conducted annually on all fire and life safety equipment by a locally licensed company under contract with DFM. DFM maintains a register (log)identifying the location all applicable fire and life safety equipment including fire alarms, smoke detectors, fire extinguishers, fire panels, emergency key egress boxes, flammable cabinets, and a division specific chemical inventory list throughout the complex. They have installed fire resistant cabinets for flammable chemicals in all maintenance shops where they are stored. DFM has implemented Policy (09-03-04) for safe and effective storage of all hazardous materials. The Chicago Fire Department has assessed the placement of flammable cabinet locations and although they
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will not provide a written acceptance as described in Provision 71 above, their representative stated that the storage locations were acceptable.
DFM maintains a binder sorted by division and by floor that show through color codes the location of all maintenance shops, mechanical rooms, closets, stairwells, plumbing chases, fire panels, and emergency key egress boxes. A copy of the binder is provided to the Chicago Fire Department, is readily accessible and provided to each division’s designated safety officer, and the DO Fire Safety Officer/ DFM participates and provides updates of issues and changes through the Fire Safety Committee.
Monitor’s !ssessment:
There is no change from the previous report. DFM maintains an up-to-date register of all fire safety and emergency devices including alarms, extinguishers, strobes, pull stations, and extinguishers for each division. I reviewed the binder described above and found it to be well organized and a valuable tool in case of an emergency/ Each division’s safety officer maintains a copy of their division’s floor plan and inventory book. Engineering Security & Sound Inc. and Door Systems Inc. have completed the 2014 fire alarm testing for all divisions. 2015 inspections are scheduled as part of preventative maintenance. Annual fire pump tests for 2015 are not due until April for all Divisions that have Fire Pumps. All inspections are included as part of the work order system.
This provision continues to in substantial compliance with the consent agreement.
Monitor’s Recommendations:
1. Assure that the fire and life safety inspections for Division VIII are included in the 2015 preventative maintenance schedule.
74. DFM shall ensure that all fire and life safety equipment is properly maintained and routinely inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the Life Safety Equipment.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Facilities Management continues to implement their policy #10-01-01, “Required Testing, Inspection, and Maintenance of Life Safety Systems/” This policy and procedure outline required testing in accordance with NFPA requirements. It includes weekly and monthly generator testing, monthly fire department connections inspection, monthly fire pump churn testing, monthly fire extinguisher inspection, annual fire pump testing, annual fire alarm testing, annual main drain testing, and annual elevator testing. Included in the policy is the requirement for documented corrective action when nonconformities are identified. Required testing, inspection, and maintenance for all life safety systems are scheduled and maintained through the “Facility Wizard” work order system as part of the preventative maintenance program.
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The fire extinguishers are all bar coded. The bar code is tied to a spread sheet allowing DFM to know the dates when annual and six year testing is required
Monitor’s !ssessment:
I did not find any issues during this tour. All fire extinguishers I checked throughout the complex had been inspected for April, 2015 and the tags updated as required. DFM maintains a report summarizing the annual testing, inspection and maintenance for all fire and life safety equipment.
Monitor’s Recommendations:
1. No further recommendations.
75. CCDOC shall continue to 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Security and Key Control Interagency Directive was issued effective January 1, 2012. It requires that each Division have a “red” emergency key access box located in the control room. That box contains the key that opens a second box containing all emergency keys for all housing unit doors. The key box is locked and has a security seal that has to be broken to gain access. The policy further requires that any time the seal is broken, including during an emergency, the Watch Commander be notified, an incident report written, and a work order submitted requiring the DFM locksmith to reseal the box.
All emergency egress keys are color coded and have a two inch glow stick attached to the key ring. Restricted keys are those specifically assigned to designated personnel with the authority of the respective division superintendent or DFM’s Deputy Director/OEIV/ These keys are color coded differently than the egress keys. General keys are specifically designated keys for everyday use including the library, classrooms, recreation rooms, etc., and are also color coded. Emergency access keys for all DFM maintenance shops and mechanical rooms and closets are maintained in the Superintendent’s office of Division XI. Emergency access keys for DFM shops for Divisions I, II, III, IV and V are housed in the Superintendent’s office in Division V/ Emergency keys for Divisions VI, IX, X and the new VIII are housed in the Superintendent’s office in Division IX/ Division XI will continue to maintain the keys for maintenance shops located there.
The emergency keys for access to all DFM shops and storage areas are located in Division IX for all shops and storage areas other than Division XI and Boot Camp. The keys for those shops are located in Division XI. The key access systems are tested quarterly by DFM to assure they are readily accessible.
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Monitor’s !ssessment:
There is no change from the previous report. During this tour I spot monitored the emergency keys in Division XI and found all emergency key rings were equipped with glow sticks as required. When asked, officers in control rooms correctly demonstrated the emergency key access procedure by breaking the seal to the locked cabinet. Training continues to be provided for Administrative Relief Teams (ARTs) on emergency key access procedure. CCDOC needs to at least annually test all emergency keys to assure they are able to open the designated locks.
Monitor’s Recommendations:
1. Establish as part of the fire safety plan a process to at least annually test all emergency keys to assure they can open the designated locks.
76. CCDOC 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. CCDOC shall conduct and document random audits to test staff proficiency in performing this task on all shifts, at a minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall communicate with DFM via the Work Order System regarding lock-related issues and maintenance.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update: Emergency keys for each division are stored in a secure control room. All keys have been equipped with glow sticks that to allow staff to easily identify a specific key in the case where vision is impaired because of smoke or fire. The Fire Safety Committee explained that on every shift, the officer assigned to the unit or tier inspects all locking mechanisms and reports any issues through the DFM work order system/ The Fire Safety ommittee has implemented an “Egress Key Exercise for each Division on all shifts by all personnel. Egress key accessibility and process are also included as part of the routine unannounced fire drills as described above.
Monitor’s !ssessment:
There is no change from the previous report. During this visit, I did not test officers on the use of emergency keys. However, in assessing emergency keys in Division XI
Monitor’s Recommendations:
1. Continue testing the egress key exercise for all divisions during fire drills.
2. Provide evidence that the testing of door locks and what to do if a lock fails is included on the correction officer’s training syllabus/
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77. DFM shall develop and implement an annual preventative maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The annual inspection of door locks, fire and smoke barrier doors, and manual unlocking mechanisms is included on the “Facility Wizard” work order system as a standing order/ DFM has a three-year contract with a local company to conduct those inspections. The annual inspections are completed by the same contractor that inspects smoke detectors, fire alarms, and smoke detectors.
Monitor’s !ssessment:
There is no change from the previous report. Between June and August, Door Systems Inc. completed its 2014 annual inspection of all door locks, fire and smoke barrier doors, and manual unlocking mechanisms through the same outside vendor that inspected smoke detectors, fire alarms and smoke detectors. The 2015 inspection will be completed as last year from June through August. I will continue to monitor compliance with this provision.
Monitor’s Recommendations:
1. Continue the monitoring program as scheduled.
2. No further recommendations.
78. CCDOC shall implement competency-based testing for staff regarding fire and emergency procedures.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC through the Interagency Fire Safety Committee has implemented the competency based safety officer proficiency examination. It is given to all safety officers. They have also completed training for divisional supervisors and shift commanders. The test is based on the Interagency Directive for Fire Safety, Emergency, and Evacuation and CCDOC General Order 24.11.1.0. There are currently two versions of the test that can be alternated between classes or trainings. The Directive specifically requires fire safety orientation for correction officers during the annual training program in accordance with the current CCDOC General Order. CCDOC has issued the division specific Orientation Handbook. It is the responsibility for all CCDOC staff to fully understand expectations and responsibilities for a variety of fire safety and sanitation topics. It includes sections on Safety and Sanitation Inspections of Living Units (General Order #24.9.9.0), Fire Safety (Interagency Directive 64.5.30.0), Egress Keys, Chain of Command, Inmate Count Procedures, and Compound Lockdown Levels. Each handbook includes a
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floor specific site map identifying key locations specific to safety within the division such as fire annunciators, extinguishers, fire alarm pull boxes, chemical control rooms, mechanical rooms, generators, and chases. Each division has a unique written test for officers to complete after reviewing the divisional handbook/ !RTs are provided the division’s Fire Safety Training binder containing a signature sheet, divisional egress key box location and divisional floor plans with emergency evacuation routs. Superintendents are required to assure that the ARTs have read and understand its contents.
Monitor’s !ssessment:
The competency based fire and emergency evacuation safety officer proficiency exam was initiated in August, 2011. The passing score for the exam is 80%. I did not have the opportunity to review this provision during this tour. However, the recommendations from the previous report remain. I am asking the Fire Safety Officer to respond specifically address recommendations 4 and 5 prior to the next tour in December, 2015.
Monitor’s Recommendations:
1. Continue training and testing until all divisional safety officers for all shifts have completed the training and demonstrated their competency.
2. Establish a course syllabus (topic outline) for each division’s training program and identify the designated trainer responsible providing the training.
3. Continue to identify and maintain documentation of remedial training for those officers who do not perform up to expectation during regular drills and actual events.
4. Prior to my next visit, provide evidence of the remedial training for the list of officers who have completed it. While an officer may have successfully passed the written examination, the validation of the training is how they actually perform during drills and actual events.
79. CCDOC shall promptly notify DFM of all electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires.
April, 2015COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC has established written procedures for the submitting work orders for all hazards including electrical. Specifically for electrical hazards, both DFM and CCDOC monitor and review any backlog weekly/ DO is fully integrated with the DFM “Facility Wizard” work order system. A review of the number of work orders filed by each division shows a marked increase in timely work orders being submitted and work completed by DFM maintenance trades. This includes electrical work orders.
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Monitor’s !ssessment:
There is no change from the previous report. During this tour, I visited the Central Kitchen, housing units in Divisions I, II, III Annex, VI, VIII, XVII and Cermak. I did not identify any electrical issues. As of this tour DFM has reduced the number of open work orders over 30 days from 33 to 3 for electrician and from 14 to five for electrical technicians since the previous tour. Again the lighting project completed two years ago has successfully reduced the number of electrical work orders from inmates tampering with the lights.
Monitor’s Recommendations:
1. No further recommendations.
80. DFM shall promptly repair all known electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires and will document repairs by the Work Order System.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The priority system established by DFM to track and monitor resolution of all maintenance requests has been operational since August, 2010. It establishes a basis for timely response to electrical and all other work order requests, submitted by CCDOC and Cermak. Electrical hazards are established as a first priority for response by either electricians or electrical technicians. Electrical and fire safety work order requests are typically resolved either the same day or the next unless there is a delay caused by part unavailability. Weekend, unless an emergency is completed on Monday. Emergency work orders are addressed within hours of the request. Weekly pending work order meetings are conducted with CCDOC to monitor and resolve all outstanding electrical work orders.
The DFM “Facility Wizard” system provides daily, weekly and monthly reports for DFM, DO and Cermak to regularly monitor status of all work orders including electrical. CCDOC and Cermak can monitor progress or lack thereof for all outstanding work orders at any time and follow up with DFM as necessary to assure timely response and repairs to electrical hazards.
Monitor’s !ssessment:
DFM continues to reduce the number of pending electrical work orders for electrical as stated in Provision 79. Reviewing the work order logs during the tour the total open work orders pending for an electrician was 89 (5 of which were pending over 30 days) and the number of pending work orders for electrical technicians was 43 (3 of which were pending over 30 days). In the previous report the number of pending electrical work orders was 102 (further 12.76% reduction.) CCDOC and DFM continue to meet weekly to review status of open work orders. I will continue to monitor the backlog each month on reports provided.
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Monitor’s Recommendation:
1. DFM should continue review with CCDOC the weekly pending work orders to assure that they are resolved as quickly as possible to reduce any threat to a fire hazard.
2. No further recommendations.
81. CCDOC shall ensure that combustibles are controlled and eliminate highly flammable materials throughout the facility and inmate living areas (e/g/, inmates’ use of paper bags as trash receptacles, ripped fire-retardant mattress covers, improvised cell light covers, blankets on cell floors, and improperly stored and labeled flammable liquids and other chemicals
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
General Order 24.11.1.1 “Sanitation, Fire Health and Life Safety Plans and Reporting” is the DO Master Sanitation Plan. Division specific sanitation plans are revised as appropriate to the General Order. The replacement program for new lighting fixtures has also eliminated inmate’s ability to use milk cartons to cover incandescent bulbs.
Inmates are required to maintain all personal belongings and commissary in their personal property bags. Inmates housed in cells are permitted one paper bag per person for trash from commissary that is required to be emptied daily.
DFM controls the storage of flammables in their shops by maintaining them in designated secure fire resistant cabinets. As discussed in Provision 73, DFM has completed the color-coded map and inventory of all flammable and hazardous chemicals and provided it to CCDOC division safety officers and Safety Administrator. So within each division, there is an up-to-date inventory of all flammables being stored in that specific division. The inventory is maintained by DFM and is readily available to first responders in case of an emergency.
Monitor’s !ssessment:
Housing units in Divisions I, II, III Annex, VI, VIII, XI, and XVII assessed during this tour continued to demonstrate less flammables (paper bags) in the cells and dayrooms. Enforcement from tier officers and supervisors to limit flammable materials within the cells was significantly improved from the previous tour. The efforts of the “ompliance Team” to reduce the amount of combustibles and flammable materials, and improve overall sanitation within the housing units have been effective.
Monitor’s Recommendations:
1. Continue enforcement by the tier officer and supervisors to allow one paper bag per cell. All bags in excess must be confiscated including those received with commissary. In dormitories, there should be no paper bags allowed, as trash containers are already provided. All other
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personal items including shoes, commissary, correspondence, books, and magazines must be required to be stored in the inmate’s personal property bag/
2. Assure that inmates are provided with a personal property bag for legal papers
3. Investigate non-flammable alternatives for delivering commissary items.
82. CCDOC 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Interagency Directive for Fire Safety, Fire Emergency, and Fire Evacuation, 64.5.30.0, was authorized effective August, 2011. The policy establishes that all CCDOC employees must receive training and become well-versed in the fire safety, emergency, and evacuation plans of the department and its divisions/ This includes safety officers/ (Note. In the divisions there are designated and trained “Safety Officers” that are equivalent to the term “fire safety officers” identified in the provision/) Further, the policy explains that “ommunication among and between DO, ermak, and DFM employees is key in assuring a safe facility, and all shall work together to implement this directive/”
The Interagency Directive requires the designation and training for all CCDOC divisional safety officers for each division at least annually. The training must be provided by or with the approval of the Cook ounty Sheriff’s Office Training Institute, through the DO Safety Office and the hicago Fire Department, and in accordance with a written course syllabus to be reviewed annually by the Fire Safety Committee.
The training of safety officers (fire safety officers) is currently provided by the CCDOC designated Safety Administrator, using the video of one of the courses previously provided by the Chicago Fire Department. Following the training, safety officers are required to pass a written proficiency examination.
Monitor’s !ssessment:
The competency based fire and emergency evacuation safety officer proficiency exam was initiated in August, 2011. The competency based fire and emergency evacuation safety officer proficiency exam was initiated in August, 2011. Safety classes were most recently held in January and April 2015. Over 240 Safety Officers including 35 who completed the course in 2014 recognized as safety officers. Demonstration of their ability to effectively use a fire extinguisher is included in the regular fire drills conducted in each division each month.
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Fire Safety Officers will provide Roll Call Training on basic housekeeping, emergency preparedness,, code changes, and use of fire extinguishers and other life safety emergency equipment. DFM and representatives of Cermak and the Central Kitchen have been included in the training. Additional training is also provided as necessary following fire drills.
As explained earlier in this report, the divisional orientation handbooks for divisional safety officers are now complete and issued. On future tours, I will continue to monitor safety officer knowledge by witnessing drills and questioning housing officers.
This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. Provide me with a current roster of safety officers from each division who are current in their training to assure that all shifts are covered.
2. The Safety Administrator needs to assure that all designated Safety Officers assigned within the divisions have received the annual training required in the Interagency Directive. Should a Safety Officer be transferred or leave CCDOC, the superintendent, prior to the transfer or leave shall provide the name of the replacement Safety Officer to the Safety Administrator.
3. Establish a process within each division that assures the superintendent that there is always a trained Safety Officer within their division on all shifts at all times.
PROVISION: G. SANITATION AND ENVIRONMENTAL CONDITIONS
83. Sanitation and Maintenance of Facilities
a. DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate maintenance of the Facility.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Department of Facilities Management has a written staffing plan for each trade that provides response to work order requests, scheduled maintenance, and emergencies for engineering, plumbing, electrical, painting, carpentry, and masons. In includes supervisory personnel for each. DFM is responsible for the maintenance and repairs of all Cook County owned facilities including CCDOC. There are assigned trades that report directly to the CCDOC complex daily. Additional tradesmen may be assigned from other county facilities to assist when there are excessive backlogs or emergencies. DFM contracts with trades provide general maintenance for two shifts and 24 hour emergency response.
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Monitor’s !ssessment:
There is no change from the previous report. Cook County restructured the Department of Facilities Management Agency in January, 2014 to created property specific facility managers. The plan assigns one General Manager at CCDOC with two property managers to manage the maintenance workload. The leadership of DFM continues to be very committed to reducing backlog of open work orders. When reviewing trend reports, the backlog in plumbing and electrical work orders continues to be reduced almost monthly. DFM continues to provide me with monthly reports of their progress to reduce these backlogs. I will continue to monitor the monthly reports for future tours. This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
b. CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The CCDOC General Order 24.11.1.0, Divisional Sanitation Plan became effective in February 29, 2012 and was revised to CCDO General Order 24/11/1/1, “Sanitation, Fire, Health, and Life Safety Plans and Reporting/”. This order is a companion order with General Order 24.9.9.0, Safety and Sanitation of Living Units which became effective December 6, 2011 and currently is under revision. Both Order revisions reflect improved practice and include specific sanitation schedules for all housing and common areas of the divisions and require documented housekeeping completion logs, inspection reports, deficiency plan for corrective action and requisition procedures for cleaning supplies.
A sanitation video has been developed that can be shown on televisions in each living unit throughout the day, when televisions are turned to that channel. Division designated sanitation officers for each division has are trained by the CCDOC Sanitarians on safe and effective cleaning and disinfecting procedures. In the General Order, Watch Commanders are responsible for reviewing the completed Daily Inspection Forms from each of the living units and filing a summary report weekly. The Support Services Superintendent and Sanitarians receive and review the weekly summary of the sanitation log from each of the divisions. The divisional sanitation plans mandate that sanitation officers observe the cleaning and disinfection of cells, dayrooms, toilets and shower facilities. Since the divisional sanitation
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plans became effective, the Sanitarians continue to conduct unannounced inspections of living units within all divisions.
CCDOC created and continues to use a designated “ompliance Team” to develop and oversee the implementation of the Divisional Sanitation General Order. CCDOC has implemented an incentive for housing unit cleanliness and order by providing microwave ovens to those living units where the rules are being followed. In other words CCDOC transformed the previous culture where cleanliness was not a priority and inmates were permitted to live and sleep in an unclean environment and where fires for cooking commissary were commonly accepted by officers as acceptable with a very different culture through the use of an incentive environment. This process establishes accountability from both inmates and officers to improve and maintain the level of cleanliness and order of the living units as well as common areas including classrooms, maintenance closets, and tunnels. Improvement in cleanliness in those housing units where microwaves have been provided is generally significant when compared to those units where they are not available.
Cermak Environmental Services has developed a written policy with input from CCDOC that establishes procedures for cleaning and disinfection of all areas for medical and mental health inmates and each of the division specific dispensaries. Its purpose as stated is to, “To ensure through collaborative departmental efforts of sanitation, prevention, maintenance, and education that all areas under Cermak Health Serv ices” (HS) authority shall be maintained clean, disinfected, well organized, and in good repair/” It establishes formal housekeeping procedures, schedule, and expectations for the building service workers responsible for completing the all cleaning and disinfection. It includes a weekly “monitoring” program conducted by building services supervisors to be submitted to the Environmental Services Director. Environmental Services has provided training of the building service workers and supervisors.
Monitor’s !ssessment:
On this tour I assessed housing units in Divisions I, II, III Annex, VI, VIII, XI, and XVII. I purposely did not schedule which Divisions I would visit throughout the week. I found that all the housing units visited were maintained clean. In most areas inmates were maintaining personal property in their assigned bags. Trash bags are limited to one bag per person per cell. The one exception to this was in Division VIII. There I again found sanitation issues within the shower areas. Soap scum continues to build up on the tiles and on the floor. Either the cleaning chemical is ineffective to remove the soap scum build-up or the showers are not being cleaned at the frequency needed to maintain them clean. It also appears that there are not enough power washers available for use. On this tour there were only two power washers for the entire Division and both were not operational because of repair issues. There should be at least one power washer for each floor, along with at least one or two reserve machines available at all times. Because the building does not have adequate floor drains throughout the housing units, there needs to be a minimum of one wet vacuum machine available on each floor to quickly clean up inmate caused floods in the dormitories.
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I also noted that inmate personal storage was significantly improved from the previous tour.
I also toured Cermak medical and mental health infirmary and emergency room. I found significant improvement in cleanliness and order. It was clear that the Cermak weekly inspections have been effective in identifying issues of cleanliness, maintenance repairs, and organization. In reviewing the onsent !greement, I found that the medical provision 43 d/ states, “ermak shall ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in examination rooms. Cermak shall ensure that hand washing stations in medical care areas are fully equipped, operational and accessible/” !s ermak has complete responsibility for cleanliness of their infirmary and remote clinics and Provision 83 b pertains to CCDOC facilities for cleanliness and sanitation, I find that this provision substantially complies with the Consent Agreement. The Medical Monitor will continue to assess Cermak sanitation Provision 43 d as part of their report.
Monitor’s Recommendations:
1. Work with chemical suppliers to identify and then implement a solution to the soap scum build-up in the showers of Division VIII.
2. Provide adequate power washers and wet vacuums for Division VIII.
3. Develop and implement a process to effectively clean and disinfect plastic drinking cups provided to medical inmates housed in Division II dorms and Cermak or eliminate the use of them and provide single service cups.
83. Sanitation and Maintenance of Facilities
c. DFM 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
DFM uses a work order tracking system (“Facility Wizard”) to manage and prioritize all maintenance requests from anywhere in the complex. The same system also is used to schedule and assure completion of preventative maintenance needs of all mechanical and fire safety systems within CCDOC, as well as at all other Cook County facilities. Both CCDOC and Cermak use the same system through an interface to submit work orders and monitor open and closed work orders. DFM has designated staff to prioritize work orders as received and send them to trades’ foremen for assignment/ DFM and CCDOC staffs meet weekly to review and address backlogs of work orders.
Facilities Management operates a seven day, 24 hour emergency hot line to receive and respond to any facility emergency reported by CCDOC or Cermak.
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Monitor’s !ssessment:
There is no change from the previous report. DFM continues to meet the requirements of this provision. CCDOC has designated trained employees within each division to create a work orders based on information from living unit officers. Reviewing the monthly logs demonstrating continuing reduction in open work orders, it is clear that DFM promptly responds to work orders following their established priority schedule. In comparing the number of “pending” work orders from March, 2012 (2,214) and March, 2015 (979), there has been a 56% reduction. This includes reductions of 39% form plumbing, 79% for electrical, 60% for electrical technicians, 59% for ironworkers, 83% for glazers, 76% for painting, 81% for tinsmiths, and 63% for bricklayers. This is evidence of continuing compliance with the provision.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
d. CCDOC shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting, and ventilation problems.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update: The DFM “Facility Wizard” work order tracking system interface has been operational at both CCDOC and Cermak since April, 2012. General Order 24.9.9.0 established an inspection protocol for sanitation and living unit officer to identify and correct non-conformances that include initiating work orders for DFM, as appropriate. The Sanitarians have also created a Power Point presentation for training living unit officers demonstrating what constitutes a needed plumbing, electrical and emergency issues. The food service contractor, CBM, also has access to file work orders through Support Services. The CCDOC Sanitarians also generate the electronic work orders.
As a result, work orders from CCDOC staff can provide work orders as soon as they identify issues. The use of the 24 hour hotline for emergency repairs assures that emergency maintenance repairs are forwarded to DFM quickly and typically respond to these within minutes.
Monitor’s !ssessment:
There is no change from the previous tour. Touring several divisions during this tour, I observed that when I identified plumbing or electrical issues, or areas in need of painting, the Sanitation officers and commanders provided copies of the work orders that had been submitted. The work orders are maintained in a binder that they update daily. Tier officers now recognize that if a work order is processed, necessary timely repairs are being made.
As a result of this tour the provision continues to be in substantial compliance.
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Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
e. DFM shall ensure adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on and annual basis for non-automated systems.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update
The status remains unchanged since previous reports. DFM continues to conduct Rounds Monitoring Policy to monitor temperature within CCDOC for all divisions. It includes measuring and recording temperatures of the exhaust and return air fans and temperatures at a pre-selected point closest to the exhaust fan and the point farthest from the exhaust fan in living units. They also measures the temperature of the hot water at the heater, check whether the hot water circulating pump is functioning according to manufacturer’s specification, along with the sewer pumps, storm pumps, and condensate pumps. Function of the generator is verified, including the oil and fuel level. Measurements of PSI for the high, medium, and low pressure systems, city water pumps, and the chilled water pumps for the fire system, are taken. The monitoring forms are typically completed by an engineer and reviewed by a supervising chief engineer or assistant chief engineer. They are utilizing a monitoring log that is maintained in the DFM offices. Monitoring is completed once on each shift, seven days per week. Exhaust and return air vent cover cleaning continues whenever a work order is submitted from CCDOC or Cermak environmental serves. DFM continues to meet the provision of the Consent Agreement.
Monitor’s !ssessment:
There is no change from the previous report. DFM maintains temperature logs and summaries for the “Rounds Monitoring” in all divisions
Vent cover cleaning continues based on work order requests submitted from the living unit or sanitation officers... DFM management continues to monitor the number of work orders filed each month for blocked vents to determine whether another complete round is necessary. During my tours of divisions, I found no blocked or plugged vent covers needing cleaning.
Monitor’s Recommendations:
1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
f. CCDOC shall notify DFM of any visible obstructions to the ventilation system.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
As discussed above, DFM staff clean and/or replace blocked or dirty vents based on CCDOC staff submitting work orders. When tier officers identify blocked vents, a work order is submitted to DFM through the work order system.
Monitor’s !ssessment:
On this tour, I found no blocked vents or vent that needed cleaning to assure air flow. At Cermak, the ventilation cleanliness was significantly improved The Sanitation Plan requires living unit officers to identify and notify Facilities Management should vents become blocked. This is no longer an issue within any CCDOC division. This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
g. Cook County shall ensure adequate lighting in all inmate housing and work areas.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
This provision is the responsibility of the Department of Facilities Management. In July, 2012 the Cook County Board of Commissioners approved a capital improvement project to replace or retrofit all lighting and light fixtures with secure fixtures that prevent inmate abuse and improve energy efficiency within the living units within all divisions. That project has been completed. Lighting in housing and work areas is no longer an issue within all of CCDOC. Fixtures requiring the use of Incandescent bulbs are no longer used in inmate cells.
Monitor’s !ssessment:
There is no change from the previous report. As a result of this project, the number of electrical work orders has dropped as expected, and as reported earlier in this report, the back log of pending electrical work order has dropped to a manageable level. This provision continues to be in substantial compliance.
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Monitor’s Recommendation:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
h. CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
As of November 1, 2013, Quality and Excellence Inc. maintains the pest control contract for CCDOC and for CBM. Cermak continues to maintain its pest control contract with Anderson Pest Control, the former contractor for CCDOC. The new contract for CCDOC requires the contractor be onsite 7.5 hours per day 5 days per week for the first six months of the contract and then 5.5 hours per day. They have provided CCDOC a map showing the location of all traps, and provide a comprehensive inspection and implement an “Integrated Pest Management” approach/ The contractor is required to complete a floor drain cleaning procedure a minimum of twice per year to prevent insect eggs and larvae from developing, and provide a 24 hour response time for complaint response. They provide a quarterly statistical report, along with electronic reports of their inspections and recommendations.
DO continues to operate a “pest control hotline” for officers to report pest activity/ Steps to prevent pest issues and infestations are reinforced at the training academy for all correction officers.
Monitor’s !ssessment:
CCDOC provided a copy of the first quarter Pest Summary from the contractor. The report shows that most of the mice trappings occur outside of Division I, VI, X, and XI. Division I, primarily because of its age and construction continues to have mice trapped within the building. There continues to be sporadic pest control issues in some areas of the complex, because of the uncontrolled neighboring properties adjacent to CCDOC such as Division XI, along with construction activity on the property. Drain flies and gnats continue to be a nuisance in several divisions. As a result, CCDOC works closely with the contractor to clean and treat shower drains. This has helped to reduce complaints and will most likely need to continue in the near future. The contractor has been responsive to special request issues and meets regularly with CCDOC staff when issues arise. The CCDOC Sanitarians receive and review the reports and maintain historic documentation of pest activity by location and pest type.
In summary, CCDOC Sanitarians continue to regularly monitor pest control issues and meet regularly with the contractor to modify their schedule and address hot spots. While some insect and rodent issues still exist, they are effectively managed through a comprehensive program.
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However, pest control is adequately and regularly monitored, trends are reviewed, and adjustments to treatments are made as necessary. This provision continues to be in substantial compliance.

Monitor’s Recommendations:

1. Continue to provide me pest control quarterly reports.

2. Continue to monitor and treat necessary areas for drain flies and gnats.

83. Sanitation and Maintenance of Facilities

i. CCDOC shall ensure that all inmates have access to needed hygiene supplies.

April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

Status Update:

CCDOC has completed and authorized General Order 24.11.6 with an effective date of March 7, 2014. The new Order states first, that upon intake, employees shall issue inmate basic hygiene supplies including soap, toothpaste, toothbrushes, and as appropriate sanitary pads. Weekly, the supply room in each division will ensure that it maintain an inventory of these supplies at a level of 1.5 times the building capacity distribute basic hygiene supplies to the living units on a pre-determined schedule. Weekly the division officers provide and inmates sign that they have received any requested supplies. CCDOC maintain the logs, which will eventually be electronic so they can monitor excess hoarding of supplies. The logs demonstrate that the inmate received needed supplies.

Monitor’s !ssessment:

The General Order that was effective just prior to the last visit. CCDOC provided copies of the logs that are being utilized. They demonstrate that inmate hygiene supplies are received by the inmates. On this tour I did not receive any complaints from inmates nor see any grievances about the lack of needed hygiene supplies. This provision is in substantial compliance.

Monitor’s Recommendations:

1. No further recommendations.

83. Sanitation and Maintenance of Facilities

j. CCDOC shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction standards. CCDOC 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.

April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

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Status Update:
iohazardous waste from ermak’s medical facility and the medical and/or dental clinics in the divisions is the responsibility of Cermak, not CCDOC. Biohazardous waste in Cermak is securely stored and placed in red bags for daily pick up by designated Cermak staff. Cermak maintains a contract for collection and final disposal of the waste.
For biohazardous waste from living units or laundry, each division maintains a supply of biohazardous spill kits within the security office and the sanitation rooms. They are replaced as needed through Support Services. CCDOC policy does not permit inmates to clean bio-hazardous spills. A new bloodborne Pathogen Decontamination General Order was issued in January, 2013. Support Services Sanitarian created a Power Point training presentation for biohazardous waste handling and cleanup that is now provided to all sanitation officers. There is a written syllabus for blood-borne Pathogen clean-up training. Cermak teaches the blood-borne pathogen training at the Academy and during inservice.
Monitor’s !ssessment:
On this tour, I found that all sharps containers were secured in all of the clinics including those in Division VIII. Biohazardous waste from the medical/dental clinics that I visited was handled appropriately. The new Power Point training tool for sanitation officers is well written, thorough, and complete. Training for sanitation officers from each division for effective clean-up of biohazardous spills has been completed and is conducted for new sanitation officers as necessary. I have reviewed the course syllabus for biohazardous waste and blood-borne pathogen training program for officers and find that it acceptable. The provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
k. DFM shall develop a policy on hazardous materials, in accordance with generally accepted correctional standards, and insure that all DFM staff is properly trained on the procedure.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
DFM maintains policy number 2010 that was revised effective May 15, 2012. It establishes the acceptable storage procedure for handling and storage of all hazardous materials. The policy requires OSHA Hazard Communication Standard 29 CFR 1910.1200 Power Point training for all new hires and annually thereafter for all DFM personnel and that a current record be maintained for all employees required to work with hazardous materials. It requires a register
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(list) be developed of all chemicals used and stored and that the inventory and material safety data sheets be provided to designated management employees for distribution to the CCDOC Safety Administrator. The policy requires reports to the CCDOC Safety Administrator of any damage or spill. It mandates the supervisor or designee of each trade to complete quarterly inspections of all shops and rooms used for storage of hazardous materials to verify accuracy of inventory sheets, labeling, and safe and secure storage for all chemicals, along with appropriate corrective action for non-conformances and handling procedures including marking, controlling, labeling, mixing, and safety precautions/ DFM management conducts random “mock surveys” of all shops and mechanical rooms since November, 2012. One of the elements included in the audit is monitoring for safe, effective storage, inventory and maintenance of chemicals.

Two documents, Understanding Policies and Procedures for tool, chemical and key control and Fire and Life Safety Duties for Engineering are both required to be displayed in the shops and a copy maintained on maintenance carts at all times.

Flammable cabinets are located in all shops/rooms where flammable materials are stored and that they are being appropriately used. DFM has completed division specific maps identifying the location of all flammable cabinets and a list of chemicals stored in each shop and/or mechanical rooms. This now includes Division VIII. They are provided to the Safety Administrator and also securely maintained in the respective division handbook located in the superintendent’s or designee’s office/

CCDOC has emergency access to all DFM maintenance rooms via secure keys located in Divisions IX and IX/ The Division Safety Officer/Superintendent’s office also maintains a current copy of all Safety Data Sheets for all hazardous chemicals stored within that division in addition to the one prominently stored at the entrance to all shops/rooms.

Monitor’s !ssessment:

There is no change from the previous report. The provision continues to be in substantial compliance.

Monitor’s Recommendations:

1. No further recommendations.

83. Sanitation and Maintenance of Facilities

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

April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

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Status Update:
CCDOC dilutes concentrated chemicals following the chemical manufacturer’s specifications from the central supply located in Division V and distributes them daily to the divisions as requested. By centrally controlling the dilution and following the chemical manufacturer’s directions, the divisions only receive properly diluted cleaning and disinfecting chemicals needed for routine cleaning and sanitizing of floors, toilets, lavatories, showers, etc. and effective cleaning and sanitizing surfaces from biohazard spills.
The chemicals used for all cleaning and disinfection are available for distribution to Divisional Sanitation Officers from the Division V Central Chemical Room. They include general purpose cleaner, a disinfectant, glass cleaner, stainless-steel cleaner, deodorizer, and bleach along with empty spray bottles and labels. Only the floor care team has access to chemicals used for floor care including Floor stripper, floor wax, floor cleaner, and floor Ssanitizer Also available from the CCDOC warehouse are mop heads, mop sticks, vacuum, power washer brooms, dust pans and squeegees, along with buckets brushes, Tyvec suits, vinyl gloves, garbage bags and eyewash stations.
Training for inmates and CCDOC employees on the safe and effective use of cleaning is taught by the Sanitarians. Training is provided to those assigned the responsibility of cleaning cells, showers, toilet facilities, dayrooms, RCDC, classrooms, tunnels, and all administrative areas. These are two hour classes daily, for one week. Each person that takes the class and successfully passes a written test is presented with a certificate of completion.
Each division maintains a supply of biohazardous spill kits in the chemical storage room as discussed earlier. Sanitation officer have been trained on the contents and how to use them in case of a spill. Spill kits are replaced as needed. Inmates are not permitted to clean up bio-hazardous spills per policy.
“Sanitation kits” have been distributed to each operating living unit to be used for inmate mattress cleaning and daily cleaning done by inmates. The crates include one spray bottle of GP Cleaner, a spray bottle of disinfectant, two brushes (one for touch surfaces and one for toilets), four rags and an instruction card. Kits are now included in the count clearing process and the tier officer is responsible to assure inmates do not misuse the chemicals. The sanitation officer on the 11pm to 7am shift is responsible to collect and restock the kits.
Monitor’s !ssessment:
There has been no change since the previous report. This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
m. CCDOC shall inspect and replace as often as needed all frayed and cracked mattresses. CCDOC shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. CCDOC shall ensure that mattresses are properly sanitized between uses.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Mattresses are replaced as needed throughout the divisions when they become no longer cleanable or beyond repair. Each division maintains a small surplus of mattresses and more are available from Central Supply. If medically ordered, Inmates in Cermak may be provided pillows and pillowcases. Each division has a designated clothing and bedding storeroom and has established procedures in place to inspect, clean, disinfect, and repair or replace mattresses before they are provided to incoming inmates. Each room has separate areas for storage of clean and soiled mattresses. Mattresses are typically removed from the cell when an inmate is moved or discharged. They are taken to the designated storeroom within the respective division for cleaning and disinfection and cleaned using GP Cleaner and disinfectant using the process described in 83l above. The mattress is allowed air-dry and returned to the cell or dormitory for use. Inmates are also permitted clean their mattress during scheduled daily cleaning utilizing the sanitation kits described above.
Hospital mattresses within Cermak are cleaned and disinfected within the cell or dormitory anytime an inmate is transferred or discharged/ ermak’s sanitation policy, formally establishes the procedure for cleaning and disinfecting them. For some hospital beds within Cermak the CCDOC mattresses were too small and did not fit the beds. It is less than on previous tours. Further, in most of the dormitory rooms there continue to be a lack of adequate hospital beds available for the number of inmates housed. As a result inmates are allowed to sleep on plastic frames (boats). Cermak has the responsibility to provide the hospital beds for inmates assigned there.
Monitor’s !ssessment:
On this visit I once again observed a few hospital beds with the small CCDOC mattresses being used. Cermak stated that they have received reassigned hospital beds, but there continues to be an inadequate number for the inmates living there. On this tour, all mattresses I observed were clean and well maintained with no tears or excessive wear. As in the last report, there continues to be inmates sleeping on “boats”/ I was not able to witness anyone cleaning any of the hospital mattresses during my onsite visit to Cermak. However several inmates interviewed in Cermak stated that the mattresses and beds are cleaned and disinfected once they are vacated.
Within the divisions I did not observe any mattresses that were frayed and cracked to the point where they could not be effectively cleaned and disinfected. CCDOC staff indicated that a new mattress typically lasts about one year before they need to be replaced. As a result, they maintain adequate
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supplies in the warehouse to replace mattresses as they are needed. The provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. For the medical tiers, ermak needs to eliminate the use of “boats” and replace them with patient appropriate hospital beds along with adequately sized mattresses in good condition that fit the bedframe.
83. Sanitation and Maintenance of Facilities
n. CCDOC shall ensure adequate control and observation of all housing units, including distribution and collection of razors and cleaning supplies. All cleaning tools and hazardous chemical shall be removed from housing areas after use.
APRIL, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC has established General Order 24.11.7.0, Inmate Razor Distribution Effective March 14, 2014. Razors used throughout CCDOC are color coded by division. The CCDOC Assistant Executive Director (AED) of Special Projects is responsible for maintaining inventory of inmate disposable razors and assigning designated staff to issue razors to each division. Each division Watch Commander is required to assure accuracy of the inventory and designate employees on each shift to verify the number of disposable razors on hand before distribution and upon their return form the inmates. Divisions are issued two biohazard waste containers with disposable plastic liners; one used to transport unused razors and one for collecting and returning used razors. The date and amount of razors are tracked in a “Disposable Razor Logbook” signed by the officer accepting the razors/ Used razors are placed in the red biohazard container designated for “used” razors and returned to the !ED for Special Projects office for safe disposal. No razors are maintained in the housing tiers or dormitories. All razors, used and unused, are audited daily to assure complete retrieval. If a discrepancy is identified, an incident report is generated. Razors are available for use by inmates on the 11pm to 7am shift Monday through Friday with the exception of holidays.
Monitor’s !ssessment:
There is no change from the previous report. However in reviewing the weekly incident reports since the last tour, there have not been any incidents reported about missing razors in any division.
The provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
o. CCDOC shall ensure that Facility Sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility Sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.
APRIL, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC employs two full time Registered Sanitarians, who report to the Superintendent of Support Services. Both Sanitarians are active participants for all areas of the consent agreement involving environmental and safety issues including chemical control, sanitation, laundry, food service, and fire and life safety. They actively participate in the review and revision of General Orders for these areas, along with developing and providing specific training programs to correction and civilian staff, and inmates. CCDOC provides them with and they regularly use measuring and testing equipment to monitor sanitation, temperatures, etc. They continue to research specific environmental issues such as pest control trends, food service, laundry, sanitation, maintenance, biohazardous materials, etc. They conduct independent sanitation audits, both for corrections and Cermak which has resulted in modification and improvements to training programs, enhanced follow up work and objective counsel with both corrections and coordinating efforts with Department of Facilities Management.
They meet regularly with the contractor for food service, pest control, division superintendents, CCDOC management, Cermak, and DFM to assess and resolve issues. As part of their inspections, they regularly speak with both inmates and staff to identify issues that need resolution. They have an integral role in the implementation and monitoring of several CCDOC policies relative to sanitation and provide direction to the divisional sanitation officers. They have trained all divisional sanitation officers on correct cleaning procedures to assure continuing effective cleaning and sanitation. CCDOC is fortunate to have selected two Sanitarians who understand institutional environmental health, along with unique correctional issues and that are able to interpret and find solutions to protect the safety and health of both inmates and fellow employees.
Monitor’s !ssessment:
There is no change from the previous report. Both Mr. Schroer and Mr. Gnacinski, along with Support Services Superintendent Sean Julian accompanied me on this tour of division housing units, laundry, food service and Cermak. They are actively working with Cermak management and environmental services to understand environmental health issues to address sanitation, cleanliness and order at there. They speak with inmates and correction officers helping them understand the public health reasons for specific policies and procedures, along with the impact of following them correctly. I find their commitment and their insight valuable as they work to solve sanitation and safety issues in the divisions.
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They have created posters on use of the laundry for personal clothing, pest issues, and handwashing for use in the housing divisions. This provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
PROVISION: G. SANITATION AND ENVIRONMENTAL CONDITIONS
84. Sanitary Laundry Procedures
a. CCDOC shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted correctional standards. To limit the spread of communicable disease, CCDOC shall ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and dry.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC currently operates its own laundry service. CCDOC currently operates laundries in Division III, V, and Division XVII. Division III and XVII sort, wash, dry and fold laundry for female inmate clothing, uniforms, linens, and blankets. Division III also processes laundry from Cermak. The laundry in Division IV is currently non-operational as the Division is closed. The food service contractor, CBM, operates a separate laundry to clean inmate worker uniforms and kitchen laundry.
CCDOC authorized General Order 24.11.3.0 effective March 7, 2014. It establishes the responsibilities assigned to the Laundry Unit Watch Commander and outlines the necessary training requirements for employees and inmates assigned to the laundry units addressing safe sorting, washing, drying, and folding procedures and appropriate sanitation precautions necessary to be taken to assure that clean laundry is never cross-contaminated with soiled laundry. The Laundry Watch Commander, in turn, is responsible to train inmate workers on the procedure, sanitation, and the use of personal protective equipment (PPE).
The policy requires all inmates to exchange soiled clothing and linen and strictly prohibits inmates from washing and drying clothing or linen contrary to the provisions of the General Order. Laundry is collected from inmates twice each week on a posted schedule. Once cleaned, it is returned typically within the same shift from when it was collected. Living unit officers who observe clothing and linen being washed by inmates are expected to confiscate all such items and issue clean, dry clothing and linens and initiate an Inmate Disciplinary Report.
The Central laundry in Division V consists of five 150-lb Unimac washers and five 170-lb Unimac dryers. The Division III laundry consists of three Speed Queen 40 lb. washers and two 40 lb. dryers. Division IV has one washer and one dryer, not currently in use. The Division XVII laundry consists of one washer
Page 48 of 58

and one dryer and is used to wash all laundry from that division including uniforms and personals. The kitchen has one washer and one dryer. Chemicals used in all washers, including bleach, detergent and sour, are electronically dispensed.
Laundry chemicals used are currently purchased from Ecolab. They include Ecostar Builder C detergent, Ecostar Destainer (Bleach), and Ecostar Sour (a pH adjusting chemical) to prevent skin irritation and fabric browning. Safety Data Sheets (SDSs) for all laundry chemicals are posted, maintained up-to-date and readily available. Bins used to hold and transport soiled clothing from the divisions and return clean clothing to the divisions are cleaned and disinfected with Clorox disinfecting wipes before clean laundry is placed in them at each laundry.
CCDOC has developed a documented monitoring system that tracks the amount of personal laundry sent to the laundry weekly; in essence monitoring how the division staff are performing and following the General Order for frequency of inmate personal clothing washing. The reports are provided at each Superintendent’s accountability meeting each week/ The laundry supervisor tracks and reports the amount by weight of laundry received from each division including linens, uniforms, and personal laundry. Division Superintendents are required to report laundry collections each week and include in their incident reports.
Monitor’s !ssessment:
In reviewing the laundry trend reports since September, 2014, inmate use of the laundry continues to increase steadily in all divisions except Divisions II, VI, IX, and XI. DO’s inmate culture for many years has been that personal laundry is often misplaced, lost, and never returned or if returned it is wet, and late and sometimes missing clothing. The use of the laundry loops has helped reassure inmates. It has been a significant challenge for officers, Sanitarians, and management to finally change the perception of laundry services. It is management’s responsibility to require accountability of tier officers and their supervisors to require detainees to no longer wash personal laundry in lavatories, showers and toilets. In those divisions where tier officers and supervisors actively promote and require use of the laundry for personal clothing, there has been continual improvement especially Division I and now Division XIV (formerly Division III Annex). Laundry usage in those divisions is at or above targeted goals. During this tour I visited the central laundry in Divisions V, III and XVII. All were maintained clean and well organized and adequately staffed with officers and inmate workers. Inmate workers were wearing appropriate PPE and following applicable procedures for handling soiled and clean clothing and linens. I observed laundry bins being disinfected before clean laundry was placed in them. Safety Data Sheets for all laundry chemicals were available. Cleaning chemicals were readily available and the dispensing systems were functioning as designed.
This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations at this time.
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84. Sanitary Laundry Procedures
b. CCDOC shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update
As stated above, CCDOC General Order 24.11.3.0 was revised to reflect current practice and policy. The policy prohibits inmates from washing and drying clothing or linen other than through the central laundry. It requires Living Unit Officers to confiscate clothing or linens being washed by inmates and issuance of clean, dry clothing and/or linen and issuance of an Inmate Disciplinary Report.
The policy and practice require uniform, personal clothing and towel exchange be conducted twice each week, sheets once per week and blankets exchanged once per month. The laundry schedule is posted in each living unit, and each division is required to include in its weekly incident report specifically which living units did not receive linen exchange as required by the policy.
Male inmate personal laundry is taken to the central laundry in Division V. Female personal laundry is washed and dried in the Division III laundry/ Laundry for females assigned to Women’s Justice in Division XVII is cleaned in that Division’s laundry. Personal laundry is returned to the inmate on the same day during the same shift from which it was collected. All laundry is washed using appropriate detergent and bleach through electronically dispensed to assure effective cleaning and disinfection.
Monitor’s !ssessment:
There is no change from the previous report. I observed the posted laundry schedule in each housing unit of each division that I toured. The laundry operates on two shifts each day to assure timely return of clean laundry. CCDOC has created posters explaining why all clothing needs to be cleaned and disinfected through the laundry, developed videos for the inmate televisions, and have taken designated inmates to visit the laundry to see firsthand the laundry process.
Based on the laundry use trending charts provided, the one issue that remains is that in Divisions II, VI, IX, and XI the use of the laundry by detainees for personal clothing is not meeting the goal of at least 85% usage by weight. One example from Division IX, Tiers 3-E, 3-F, and 3-G only 10 inmates out of 126 utilized the laundry services. There, inmates are using the laundry service as provided, claiming that it does not get done, white clothing comes back grey. As a result, some inmates are using soap purchased through commissary to wash clothing. As this provision continues the steps to demonstrate substantial compliance, I will reassess on the next tour. Without significant improvement, it will revert back to partial compliance on the next tour.
Monitor’s Recommendations:
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1. Continue to monitor laundry usage for each division and report changes to management as necessary.
84. Sanitary Laundry Procedures
c. CCDOC shall train staff and educate inmates regarding laundry sanitation policies.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Inmate laundry workers assigned to the laundry are trained as to their responsibilities by officers assigned to General Order 24.11.3.0. The Order states the training includes both classroom and handson instruction as to the responsibilities, acceptable laundry sanitation practices and the use of laundry equipment, chemicals and the use personal protective equipment (PPE).
Monitor’s !ssessment:
There is no change from the previous report. On the tour of laundries, I observed laundry officers and inmate laundry workers. All were wearing appropriate PPE, including gloves, and uniforms following instructions, and safely handling clean and soiled laundry. This provision continues to be substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
84. Sanitary Laundry Procedures
d. CCDOC 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Clean inmate laundry is returned to the division from which it came in clean bins that are sanitized with a disinfecting bleach wipe before clean clothing, uniforms, bedding etc. are placed in the carts. All carts are thoroughly wiped by laundry workers and allowed to air dry. There are designated areas within each laundry that separate dirty laundry bins from those that have been cleaned and sanitized. Designated tables in each laundry are only used to sort and fold clean laundry. The tables are cleaned and disinfected at the beginning and at the end of each shift.
Monitor’s !ssessment:
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There is no change from the previous report. During tours to selected laundries, I again observed inmate workers properly disinfecting laundry bins before clean laundry was place in them.
Monitor’s Recommendations:
1. No further recommendations.
84. Sanitary Laundry Procedures
e. CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
General Order 24.11.3.0 specifically prohibits inmates from washing and drying clothing, towels, or linen other than through the designated CCDOC laundry. Further as discussed in Provision 84.a, living unit officers are required to confiscate any clothing or linen items being washed and replace them with clean dry clothing and/or linen/ Inmate’s uniform, personal clothing, linens and blankets are collected twice each week in each housing unit in every division as prominently posted in the unit.
Use of the CCDOC laundry system for uniforms, towels, linens, and blankets is for the most part universally accepted and practiced. There continue to be some inmates, who because of past culture continue to refuse to exchange even though CCDOC has posted easy to understand posters, schedules, and shown videos on televisions. CCDOC provides laundry loops for inmate personal clothing and assists inmates in their correct use to help assure that their clothing will not get lost. Personal laundry is returned to the inmate typically on the same shift of the same day it was collected. CCDOC has also removed laundry soap from the commissary order form to preclude inmates from doing their own laundry... As discussed in 84.a, CCDOC continues to monitor by weight the amount of personals submitted.
Monitor’s !ssessment:
The trend reports for measuring laundry use for personal laundry by inmates that provided during this tour clearly demonstrate continual significant improvement in inmate’s use of the laundry for personal laundry. During tours of housing units, I continue to see less inmate personal clothing drying on bunks or in the showers. I observed in all divisions I visited on this tour and on the previous tour that in the same division most living unit officers are enforcing the policy. The culture is clearly changing for both the inmates and the officers. Sergeants and Lieutenants must continue to be vigilant in assuring housing unit officers are following the policy. I do not believe that CCDOC can ever get 100% compliance, but reports continue to demonstrate significant improvement over time.
Monitor’s Recommendations:
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1. Continue to regularly monitor and track the use of the laundry and as discussed above include a discussion and expectations as regular agenda topic at Divisional Superintendent’s accountability meetings. Division Superintendents must be responsible and accountable to continue reinforcing use of the laundry within their divisions.
2. Revise the inmate video on the established laundry process that explains the process for uniforms, linens, and personal laundry. The video can show that the schedule for inmate laundry pick-up is posted in each housing unit.
3. The inmate handbook and laundry policy, when finalized, needs to include the current rules and expectations that clearly state that washing and drying personal laundry and linens outside of the CCDOC laundry procedures is expressly prohibited and explain the public health reasons for it.
85. Food Service
a. CCDOC shall ensure that all food service at the Facility is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC provides meals to inmates through the use of a contracted service through two kitchens located in Division V and Division XI. CBM Premier Management continues to provide food service for CCDOC inmates as started in September, 2012 The Central Kitchen in Division V prepares and serves all cold breakfast and lunches for all divisions and the hot dinner for all divisions except Division XI The Division XI kitchen is only used to prepare and serve the hot meal for that division. Equipment in both kitchens continues to be well maintained and operational. The two new steam cookers are expected to be operational once the steam permits are issued by the City of Chicago.
CCDOC provides one hot meal and two cold meals each day, as required by the State of Illinois Department of Corrections. The meals are based on a menu that has been reviewed and approved as meeting the USDA dietary guidelines by a Registered Dietician. The menu follows a four week cycle that repeats. CBM, along with a review by Cermak and CCDOC, provide medical diets including dental soft, clear liquid; full liquid, food hypersensitivity/allergies; pregnancy, nutrition support, 2400 calorie diet, and renal diet. Medical diet meals are only provided, when prescribed by Cermak medical staff. Religious diet meals provided include Kosher and Vegan. Religious meals may be ordered by CCDOC or social worker. Detainees receiving medical and religious diet meals have limitations in the selection of commissary foods they may purchase based on their medical or religious beliefs.
CBM maintains responsibility for sanitation and maintenance of all equipment. They have two maintenance technicians who work on a schedule that allows for weekend coverage as needed. Area and equipment cleaning and sanitation are done by inmate workers who are trained and supervised by CBM employees and CCDOC security staff.
Page 53 of 58

CCDOC, along with CBM, continue to assess and make improvements to reduce the delivery time of transporting the food from the Central Kitchen to all divisions to assure that inmates receive safe hot food and cold food. When CCDOC reduced the number of medical and religious diet options, the time to sort meals once they are received in the divisions improved considerably. CCDOC Sanitarians regularly monitor and record food temperatures at the time of delivery to compare it with recorded temperatures taken as the food is placed in trays in the kitchens. As a result, the number of inmate grievances regarding temperature of hot meals has reduced to less than one per month. CCDOC Sanitarians, kitchen security officers and Superintendent Sean Julian meet weekly with CBM to review any grievances and address both operational and logistic issues. A meeting summary is produced following each meeting. It includes a running list of outstanding issues including resolutions.
CBM regularly measures and records food temperatures as food is placed in trays and as it leaves the kitchen to the divisions. Division staff also record food temperatures at delivery to the inmates.
Tool control in the kitchen is maintained by CCDOC security staff for kitchen sharps that have an edge or point such as dough cutters, probe thermometers, knives, etc. and by the contractor for kitchen utensils. All tools, along with all chemicals are routinely inventoried daily and there is a sign in/sign out log maintained in the control room for each kitchen.
CCDOC Sanitarians conduct unannounced inspections of both food service operations to assure that meals prepared are safe and that they are operated in accordance with Illinois Food Code regulations. They also review the regulatory inspections of both kitchens completed by the City of Chicago Health Department and meet with CBM to assure corrective actions are taken for all violations identified.
Monitor’s !ssessment:
CBM has and continues to work closely with CCDOC Support Services staff to identify and resolve issues related to food service. On this tour, monitors heard numerous complaints from inmates about food quality and the lack of variety. The quality and variety complaints, while not part of the consent agreement have increased significantly since the previous visit. CCDOC and CBM should take these complaints seriously and initiate dialogue with inmates and staff as a basis for making necessary changes. As recommended in past tours, it may be beneficial to establish and maintain open communications between inmates from the divisions, along with CCDOC corrections staff.
CBM provide cold meals on reusable trays and eliminated Styrofoam trays which inmates would save and use to block air vents. Trays are collected following each meal service and returned to the kitchen for washing and sanitizing. Separate reusable compartmented style trays are used for serving the hot meal. CBM has developed and implemented documented employee and inmate worker training programs, their internal inspection program, temperature monitoring program, formal staffing plans for employees and detainee workers, weekly cleaning schedules, a number of Standard Operating Procedures (SOPs), security standard and procedures, inmate kitchen worker orientation checklist, health screening, emergency evacuation plan in compliance with the fire safety committee, and an emergency food service contingency plan.
Page 54 of 58

ON this tour I again noted that both kitchens including storage rooms, refrigerators, freezers, loading docks were maintained clean and well organized. Inmates were appropriately supervised and working efficiently. At the time of my visit, the inmate workers were loading trays for the dinner meal and also preparing and packaging the next day’s cold breakfast.
This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations pertaining to the provision. However, investigate inmate complaints about food quality and variety and implement improvements to both.
85. Food Service
b. CCDOC shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
All CBM management employees are Certified Food Safety Managers through the accredited Serv-Safe program and documentation is maintained showing that “Food Manager ertification” certificates that are current. CBM has established written job descriptions for all employee positions that include responsibilities and tasks. CBM provides regular training to inmates using a check list that is signed by CBM staff and the inmate kitchen worker demonstrating that they have received and understand the food safety training pertaining to their assigned responsibilities. CCDOC Sanitarians developed an inmate training video that addresses health issues and personal hygiene that is shown to all potential inmate workers before they are assigned to work in the kitchens.
Monitor’s !ssessment:
There is no change since the previous report. The State of Illinois requires food service managers to successfully complete a “State” approved food manager certification program/ M posts the Serv-Safe Food Manager Certification Certificates for those employees who have successfully completed the training in the employee break room.
This provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
Page 55 of 58

85. Food Service
c. CCDOC shall ensure that the Central Kitchen and Division XI kitchen are staffed with a sufficient number of appropriately supervised and trained personnel.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CBM maintains a staff of 57 full or part time employees with schedules to assure adequate coverage for all meals daily and including weekdays. They have a written food service staffing guide that outlines the starting and ending times for all employees. The kitchen operates two shifts, as cold meals are prepared in advance of their serving, and maintained refrigerated as necessary. Additionally they utilize approximately 230 detainees scheduled over three, six to eight hour shifts just in the central kitchen to work in a variety of food service operations including preparation, filling meal trays, sanitation, warewashing, etc/ Division XI inmate workers from that Division are assigned to work in that Division’s kitchen to prepare and tray only the dinner hot meal. The contractor is responsible for training and supervising their employees and the inmate workers assigned to the kitchen. CCDOC provides inmate workers as needed. They also provide security officers for safety supervision of inmates and for tool control and staff to transport and serve the prepared meals to all divisions delivered either by transport truck or by carts utilizing the tunnels. CCDOC provides the security training of kitchen staff.
Monitor’s !ssessment:
There is no change from the previous report. My assessment including discussions with Support Services Superintendent and the Sanitarians demonstrated that CBM continues to maintain adequate number of qualified, trained and workforce at all times to assure timely preparation and service of meals to detainees. Regular weekly meetings between CCDOC Support Division including the staff sanitarians, security staff, CCDOC management and CBM leadership include discussions of adequate staffing as well as other issues. As reported in previous reports, CCDOC provides sufficient staff to adequately supervise the safety and security of inmates assigned to work in both kitchens and provide effective tool control. The provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
85. Food Service
D. CCDOC shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Page 56 of 58

Status Update:
Equipment, utensils, and food preparation rooms, floors, walls, are maintained clean through shift and daily cleaning schedules established by CBM. They have created and implemented written cleaning procedures for all equipment in accordance with the equipment manufacturer’s specifications and a cleaning checklist/log for both kitchens along with a daily and weekly cleaning schedule for each room and the equipment in the kitchens such as the meat/packing room, wet room, bakery/packing room, dock, dry storage areas. It identifies what is to be cleaned, the frequency for cleaning and who is responsible for the cleaning. CBM trains, uses, and supervises inmate workers to clean and sanitize all areas identified on the cleaning schedule. Once completed, the supervisor initials the log and the records are maintained and are available for the Sanitarians to review during their inspections. The trays used for all meals are washed and sanitized after each meal and the cleaned trays are stored on appropriately designed racks that allow water to drain and the trays to dry between uses.
Monitor’s !ssessment:
There is no change from the previous report. CBM continues to maintain all food service areas, equipment and utensils exceptionally clean. The kitchens are maintained as a model for institutional food service facilities. This includes walk-in refrigerators, freezers, dry storage areas, food preparation and assembly rooms, warewashing, carts used to transport food to the divisions, offices and laundry Both inmate workers and employees understand the expectation for cleanliness and disinfection of surfaces. Management and supervisors expect and demand excellence from employees and inmate workers. Inmate workers are quickly replaced when they do not perform to expectations.
This provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
85. Food Service
e. CCDOC 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.
April, 2015 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The temperature monitoring and recording program implemented by CBM and monitored regularly by CCDOC Sanitarians demonstrates that this provision remains in substantial compliance. CBM has implemented an appropriate monitoring program to measure, record, and maintains logs for all refrigerators, freezers, and warewasher equipment. Logs of the temperature measurements are not only reviewed by CBM management, but also provided to the CCDOC Sanitarians weekly. Any required
Page 57 of 58

maintenance deemed necessary as a result of monitoring is completed by trained CBM maintenance workers. CCDOC Support Services Sanitarians, as well as regulatory inspectors continue to do independent monitoring of temperatures during their routine during unannounced inspections of both kitchens. Monitor’s !ssessment: There is no change from the previous report. I again reviewed temperature logs for several refrigerators and freezers in the central kitchen during this tour. The monitoring logs were current, legible and reviewed by management. This provision remains in substantial compliance. Monitor’s Recommendations: 1. No further recommendations.
Page 58 of 58

 
 Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 1 of 47 PageID #:4674

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

UNITED STATES OF AMERICA,
Plaintiff,
v.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants,

No. 10 cv 2946 Judge Virginia Kendall

Monitor Harry E. Grenawitzke's Report No. 11 April14, 2016

Harry E. Grenawitzke, RS, MPH, DAAS Grenawitzke & Associates, LLC SO Sheridan Drive Monroe, MI 48162 E-mail: harry.grenawitzke@gmail.com

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 2 of 47 PageID #:4675
Executive Summary
March 7-9, 2016
This report summarizes the findings from the 11th tour of CCDOC. As in all previous tours the pu rpose was to observe evidence of compliance and progress made in accordance with the provisions of the Consent Agreement between the US Department of Justice Civil Rights Division and Cook County. During the previous tour all 39 provisions were found to be "substantially compliant" with the Agreement. As a result the focus of the visit changes as CCDOC now is required to demonstrate sustainability with all of the provisions.
Judge Virginia Kendall, Judge of the Northern District of Illinois, Eastern Division concluded several provisions for which the Cook County Department of Facilities Management DFM) were responsible to demonstrate compliance. While the concluding order did not include the provisions specifically, the Monitor identified eight provisions with DFM responsibility as F.73, F-74, F-77, F-80, G-83a, G-83d, G83e and G-83 k. As a result, the Monitor did not include them in this tour. Further two provisions for which DFM assumed responsibility for compliance include provision C-53.e which required " Cermak shall ensure that the negative pressure and venti lation systems function properly. Following CDEC guidelines, Cermak shall test daily for rooms that are in-use and monthly for rooms not currently in use. Cermak shall document such testing." DFM accepted responsibility and has and continues to monitor these negative pressure rooms since January, 2013. Provision G-83g states, "Cook County shall ensure adequate lighting in all inmate housing and work areas." DFM assumed the responsibil ity demonstrate compliance. As stated in previous reports, DFM completed a replacement of all the deficient lighting throughout the CCDOC housing and work areas as part of a capital project in 2013. Because DFM complied with the Agreement and because of the length of time for which they were found to be "substantially compliant", the Monitor considered these two additional provisions
Page 2 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 3 of 47 PageID #:4676
as having "demonstrated sustainable and did not monitor them as part of this tour.
Demonstrating sustainability with the provisions can be a both a challenging and rewarding process. CCDOC is well into a process of developing and implementing an internal auditing system to measure staff accountability for appropriately implementing general orders and procedures. They are commended for developing Policy 2276, Internal Audit, the purpose of which is to provide a guideline for documenting that all Cook County Sheriff's Office policies and procedures relative to jail operations followed. They have completed an audit of the laundry unit process and were finishing an audit of the emergency key control. CCDOC completed an internal auditing training course for 30 staff and are planning a second course for late spring. The auditing policy requires staff accountability to determine root cause of all non-conformities identified and a documented corrective action plan and formal close out, once completed.
Similarly, Cermak is in the development stage to create an audit platform for its services. The initial focus will be on their environmental services. The Monitor will continue to review progress during future tours. They also plan to conduct internal audit training for designated staff.
Separate, but related starting in January, 2016 Cook County Sheriff's Office is continuing to overhaul department policies and procedures for the Department of Corrections by the Office of Policy and Accountability. Hey are using Lexipol, a risk management firm to assure policies and procedures developed meet industry standards and are implemented practically and effectively. The project is expected to be completed in 18 months. Included will be "Daily Training Bulletins" to keep employees abreast of policy and procedure updates and continue employee compliance.
For this tour the Monitor assesses implementation of policies and procedures established to address the fire and life safety and environmental health provisions
Page 3 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 4 of 47 PageID #:4677
for Cook County Department of Corrections (CCDOC) and Cermak M edical and Mental Health Facilities (Cermak). As part of the tours I interviewed inmates in all divisions visited, correction staff, supervisors, division superintendents, Support Services staff, maintenance personnel, and leadership and staff of Cermak. The results of the tours and responses from conversations provide the information included in this report. The divisions assessed include Divisions IV, VI, VIII, and Cermak. All provisions remained "substantially compliant." Only two of the 30 remaining provisions (G-83.b and G-83.i) have not yet demonstrated substantial compliance for 18 months as required in the agreement. Significant progress and improvements highlighted in the report include:
1. Continued reduction of detainees to less than 9000. 2. Closing Divisions I, Ill, XVII and relocating detainees. 3. Re-opening Division IV after extensive repairs. 4. Continued improvement in sanitation in most divisions; 5. Implementations of the policy to assure detainees have ready access to
hygiene items. 6. Continued significant reduction in the maintenance backlog for all work
orders, but specifically plumbing and electrical; 7. Development of internal auditing process for CCDOC. 8. Improved use of the CCDOC laundry for inmate personal clothing. 9. Significant improvement in maintaining shower facilities in Division VIII
clean. 10. Improved assessment of fire drills and fire investigations designed to
improve training and assess staff competency.
Page 4 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 5 of 47 PageID #:4678
11. Continued improvement in DFM response to work order requests. Several CCDOC housing staff remarked that the response and resolution time is much shorter than in previous years.
As of the completion of this tour, all 39 provisions of the Consent Agreement are now deemed to be "substantially compliant." Congratulations. This could not have happened without the dedicated commitment and leadership displayed by management and staff of all three entities. I want to extend my appreciation to the leadership and staff of CCDOC, DFM, and Cermak for their commitment, dedication, support and time to provide countless documentation prior to and after the tour. The cooperation and willingn ess of Nneka Jones Tapia, and Matthew Burke, and their staff at CCDOC; Bilqis Jacob-EI and staff from DFM; and Chris Wurth from Cermak to share their ideas and suggestions for improvement are clearly recognized. I also want to recognize Sheriff Thomas Dart for his leadership to establish the expectation to continually assess and improve the conditions of confinement at CCDOC. As always I remain available to assist staff as necessary
Sincerely,
cfta~t."'J.J.. 3-~t.en.awitzl<e, RS, MPH, DAAS Monitor for Fire, Life Safety and Environmental Health
Page s of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 6 of 47 PageID #:4679

Section

c.

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Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently inuse . Cermak shall document results of such testing.
Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems.
Fire and life Safety

3/ 11 9/ 10 8/11 7/12 12/11 2/13 9/13 3/14 10/14 4/15 3/16 7/12 3/11 2/13 8/11 9/13 12/11 3/14 10/14
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F. 71

CCDOC and DFM shal l work together to develop and implement a fire safety program and ensure compliance is appropriately documented. The initial Fire Safety Plan shall be approved by the fire prevention authority having jurisdiction. The Fire Safety Plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and emergency procedures shall be standardized across divisions, to the extent possible given differences in physical pla nt and security levels.

12/11 7/12 2/13 9/13
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9/10 3/11 8/11

F. 72

CCDOC shall develop and implement an evacuation plan for inmates 12/11 and staff and ensure that comprehensive fire drills are conducted 7/12

Not Assessed
Page 6 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 7 of 47 PageID #:4680

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every three months on each shift. CCDOC shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
DFM shall ensure that the Facility has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable fire codes. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures in accordance with City of
Chicago Fire Code (13-76-010).

2/13 9/ 13 3/ 14 10/ 14 4/ 15 3/16

9/10 3/11 8/ 11

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

DFM shall ensure that all fire and life safety equipment is properly ma inta ined and routine ly inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the Life Safety Equipment.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

CCDOC shall continue to ensu re 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.
CCDOC 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. CCDOC shall conduct and document random audits to test staff proficiency in performing this task on all shifts, a minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall

2/13 9/13 3/ 14 10/ 14 4/15 3/16 2/ 13 9/ 13 3/ 14 10/14 4/15 3/16

9/10 3/11 8/ 11 12/11 7/12
9/10 3/11 8/ 11 12/11 7/12

Page 1 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 8 of 47 PageID #:4681

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communicat e with DFM via the Work Order System regarding lockrelated issues and maintenance.

F. 77

DFM shall develop and implement an annual preventative maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in t he event of an emergency.

CONCLUDED BY ORDER OF JUDGE KENDALL6/22/ 15

F. 78 F. 79 F.80 F. 81

CCDOC shall implement competency-based testing for staff

regarding fire and emergency procedures.

-

CCDOC shall promptly notify DFM of all electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires.
DFM shall promptly repair all known electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires and will document repairs by the Work Order System.

8/11 12/11 7/12 2/13 9/13 3/14 10/14 4/15 3/16 7/12 2/ 13 9/13 3/14 10/ 14 4/15 3/16

Not assessed 9/10 X3/11
9/10 3/11 8/11 12/11

CONCLUDED BY ORDER OF JUDGE KENDALL6/22/ 15

CCDOC shall ensure that combustibles are controlled and eliminate hi8ghly flammable materials throughout the facility and inmate living areas (e.g., inmates 'use of paper bags as trash receptacles,

9/ 13 3/14 10/14

3/ 11 8/ 11 12/11

9/ 10

Page 8 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 9 of 47 PageID #:4682

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ripped fire-retardant mattress covers, improvised cell light covers, blankets on cell floors, and improperly stored and labeled flammable liquids and other chemicals).

4/15 3/16

7/12 2/13

F.82 G

CCDOC 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.
SANITATION AND ENVIRONMENTAL CONDITIONS

7/12 2/13 9/13 3/14 10/14 4/15 3/16

Not Assessed 9/10 3/11 8/11

G. 83

Sanitation and Maintenance of Facilities

G.83a

DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate ma intenance of the Facility.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/ 15

G.83b G.83c

CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. Such policies should include oversight and supervision, including meaningfu l inspection processes and documentation, as well as establish routine cleaning requirements for toilets, showers, and housing units.

4/15 3/16

DFM 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.

9/10 3/11 8/11 12/11 7/12 2/13 9/13 3/14 10/14

CONCLUDED BY ORDER OF JUDG E KENDALL 6/22/ 15

G.83d CCDOC shall notify DFM, in a timely manner, of routine and

7/12 8/11

9/10

Page 9 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 10 of 47 PageID #:4683

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emergency maintenance needs, including plumbing, lighting, and ventilation problems.

G.83e

DFM shal l ensu re adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on and annual basis for non-automated systems.
CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

2/13 9/13 3/14 10/14 4/15 3/16

12/11

3/11

G. 83f G. 83g G.83h

CCDOC shall notify DFM of any visible obstructions to the ventilation system.
Cook County shall ensure adequate lighting in all inmate housing and work areas.
CCDOC shall ensure adequate pest control throughout the housing un its, medical units, RCDC, RTU, and food sto rage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.

7/12 2/13 9/13 3/14 10/14 4/15 3/16 2/13 9/13 3/14 10/14 4/15 3/16 2/13 9/13 3/14 10/14 4/15 3/16

3/11 8/11 12/11
9/10 3/11 8/11 12/11 7/12
9/10 3/11 8/11 X12/11 X 7/12

9/10

Page 10 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 11 of 47 PageID #:4684

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CCDOC shall ensure that all inmates have access to needed hygiene supplies.
CCDOC shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction standards. CCDOC shall ensure that any inmate or staff utilized to clean a biohazardous area are properly trained in un iversal precautions, are outfitted wit h protective materials, and receive proper supervision when cleaning a biohazardous area.

4/15 3/16
2/13 9/ 13 3/ 14 10/14 4/15 3/16

Not Assessed
9/10 or 3/11 8/11 12/11 7/12 2/13 9/13 3/14 10/14
Not Assessed
9/ 10
3/11 8/11 12/11 7/ 12

G. 83k G. 831

DFM shall develop a policy on hazardous mate rials, in accordance with generally accepted correctiona l standa rds, and insure that all DFM staff is properly trained on the procedure.

CONCLUDED BY ORDER OF JUDGE KENDALLG/22/ 15

CCDOC shall provide and ensure t he use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.

8/11 12/11 7/12 2/ 13
9/13
3/14 10/14 4/15 3/16

Not Assessed
9/10 3/ 11

Page 11 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 12 of 47 PageID #:4685

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CCDOC shall inspect and replace as often as needed all frayed and cracked mattresses. CCDOC shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. CCDOC shall ensure that mattresses are properly sanitized between uses.
CCDOC shall ensure adequate control and observation of all housing units, including distribution and collection of razors and cleaning supplies. All cleaning tools and hazardous chemical shall be removed from housing areas after use.

8/11 2/11 7/12 2/13 9/13 10/14 4/15 3/16 8/11 12/11 7/12 2/13 9/13 3/14 10/14 4/15 3/16

3/11
9/10 3/11

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CCDOC shall ensure that Facility sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.
Sanitary laundry Procedures

12/11 7/12 2/13 9/13 3/14 10/14 4/15 3/16

9/10 3/11 8/11

G. 84a

CCDOC shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted correctional standards. To limit the spread of communicable disease, CCDOC shall ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and dry.

8/11 12/11 7/12 2/13 9/13 3/14 10/14

9/10 3/ 11

Page 12 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 13 of 47 PageID #:4686

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G. 84b G. 84c G. 84d
G.84e

CCDOC shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas.
CCDOC shall train staff and educate inmates regarding laundry sanitation pol icies.
CCDOC 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.
CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures. (* In the Monitor Report #V dated July 20, 2012; this provision was inadvertently recorded "substantial compliance." The provision should have been recorded "partial compliance.")

4/15 3/16 3/14 10/14 4/15 3/16
3/14 10/14 4/15 3/16
12/11 7/12 2/13 9/13 3/14 10/14 4/15 3/16 9/13 3/14 10/14 4/15 3/16

3/11 8/11 12/11 7/12 2/13 9/13 8/11 12/11 7/12 2/13 9/13 9/10 3/11 8/11
9/10 3/11 8/11 12/11 7/12* 2/13

9/10
9/10 3/11

G.SS Food Service

G.85a

CCDOC shall ensure that all food service at the Facility is operated in 9/13

a safe and hygienic manner and that foods are served and

3/14

3/11

9/10

8/11

Page 13 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 14 of 47 PageID #:4687

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G.85b G. 85c G.85d G.85e

maintained at safe temperatures.
CCDOC shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanit ation.
CCDOC shall ensure that the Central Kitchen and Division XI kitchen are staffed with a sufficient number of appropriately supervised and trained personnel.
CCDOC shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
CCDOC 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.

10/14 4/15 3/16 7/12 2/13 9/13 3/14 10/14 4/15 3/16 2/13 9/13 3/14 10/14 4/15 3/16 2/13 9/13 3/14 10/14 4/15 3/16 7/12 2/13 9/13 3/14 10/14 4/15 3/16

12/11 7/12 2/13 9/10 3/11 8/11 12/11
9/10 3/11 8/11 12/11 7/12
9/10 3/11 8/11 12/11 7/12
9/10 3/11 8/11 12/11

STATUS REPORT

Page 14 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 15 of 47 PageID #:4688
DATE OF STATUS REPORT: 4/14/16 PROVISION: C. MEDICAL CARE 53. Treatment and Management of Communicable Disease
e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing. March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: Since July, 2012 the Department of Facilities Management (DFM) continues to monitor and record the results of the negative pressure testing for the 18 isolation cells located on the third floor (3-E} of Cermak, along with the enunciator panel once each shift. The records are maintained in the DFM office located in the Cook County Courthouse. Work orders are submitted and appropriate repairs anytime monitoring demonstrates non-compliance. Occupational and Environmental Hygiene Services at the Great Lakes Center for Occupational and Environmental Safety and Health at the University of Illinois, Chicago, conducts a full testing ofthe ventilation system annually. Copies ofthose reports are provided to the Chief Medical Officer of Cermak. Monitor's Assessment: There is no change from the previous report. The pressure monitoring by DFM is included in their Preventative Maintenance Schedule. This provision continues to be in substantial compliance. Monitor's Recommendations:
1. No further recommendations. PROVISION: C. MEDICAL CARE 53. Treatment and Management of Communicable Disease
f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems. March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Page 15 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 16 of 47 PageID #:4689
Status Update:
Cermak submits work order requests through the "Facility Wizard" work order system utilized by DFM for both emergency and routine repairs as well as scheduled maintenance. Cermak's Environmental Services Director or Assistant Director of Plant Operations/Environmental Services are trained and authorized to enter work order requests to DFM electronically. Since 2012 they have the capability t o review the status of all Cermak's wo rk orders at any time using the online database.
Monitor's Assessment:
Cermak's Environmental Services Director resigned in February, 2016 and Cermak is in the process of selecting his replacement. Cermak, along with CCDOC Sanitarian and DFM continue to do monthly environmental rounds throughout Cermak infirmary and the division specific clinics. The inspections along with staff requests have significantly improve and assure timely submission of work order requests. Management staff at Cermak report excellent response by DFM to quickly respond and resolve maintenance issues.
Cermak management is beginning a process to establish a formal internal auditing process for all environmental services. Internal audit training is expected to be completed in Apri l, 2016.
Monitor's Recommendations:
1. Establish and implement an ongoing internal audit policy and procedures that includes identificat ion and regular monitoring of work orders to assure timely response to assure sustainability of the provision.
2. Submit audit reports to the Monitor for review once audits are implemented.
PROVISION: F. FIRE AND LIFE SAFETY
71. CCDOC and DFM shall work together to develop and implement a fire safety program and ensure compliance is appropriately documented. The initial Fire Safety Plan shall be approved by the fire prevention authority having jurisdiction. The Fire Safety Plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and emergency procedures shall be standardized across divisions, to the extent possible given differences in physical plant and security levels.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Page 16 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 17 of 47 PageID #:4690
Status Update:
The Interagency Committee consisting of the Directors of CCDOC, DFM, and Cermak created the Fire Safety Committee (FSC) in August, 2010 They meet monthly to review and assess the fire safety and prevention systems including drill videos and reports and make improvements as needed. The program is documented in accordance with the provisions of the consent agreement. The Fire Safety committee consists of representatives from the Office of the Sheriff, CCDOC, Cermak Health Services, and DFM. Each division within CCDOC has a documented "Fire Safety and Emergency Plan" which includes a detailed emergency evacuation procedure. The plans are reviewed biannually by the City of Chicago Fire Department. Annually the City of Chicago fire safety inspectors complete an inspection of CCDOC. Scheduled, unannounced fire drills are conducted regularly on all shifts for all divisions. When available, an inspector from the Fire Prevention Bureau, along with the responding fire station firefighters participates as part of their response training.
CCDOC, DFM, and Cermak issued the Interagency Directive, 64.5.30.0, effective August 22, 2011 that establishes the policy and procedures for Fire Safety Plans, fire emergency response, and evacuations within CCDOC. The Directive establishes the respective roles and responsibilities for CCDOC, Cermak, and DFM relating to Fire Safety Plans, emergencies and evacuations. CCDOC has a designated fire safety administrator and fire safety officer position and each division has designated trained safety officers assigned for each shift including weekends and holidays. Fire Safety Training is provided as part of initial correction officer orientation program at the Training Institute located in Moraine Valley Community College. These classes are taught by Deputy Director Cook County Sheriff's Office, Training Institute, who also chairs the interagency Fire Safety Committee.
The Fire Safety Interagency Agreement requires divisional Safety Officers to conduct weekly fire safety inspections of all housing, administrative, medical clinics, storerooms, maintenance rooms, classrooms, and common areas within their respective divisions. Living Unit Officers or Post Officers, as appropriate are to conduct documented inspections on the 2300 -0700 shift and record findings on the Living Unit Inspection Form. CCDOC General Order 24.11.1.0 was revised to require these inspections. General Order 24.11.1.1 was issued on October, 3, 2014
Monitors Assessment:
Interagency Directive 64.5.30.0 is presently under review by the Fire Safety Committee as part of a recently initiated lexipol policy and procedure initiative for Corrections. A presentation of the initiative was provided during the tour. The Fire Safety Committee continues to provide summaries of its meetings that include investigation reports of all fires and fire drill reports.
Page 17 o f 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 18 of 47 PageID #:4691
The meeting summaries have improved significantly and include objectives for the meeting, thorough discussion of the items, old and new business. CCDOC provided meeting summaries for Dec 17,2015, Jan. 21, Feb.18, and March 1, 2016.
CCDOC provided correspondence dated January 11, 2016 for the annual review and acceptance of the CCDOC fire evacuation and emergency plans. They also provided correspondence dated January 11, 2016 of the most recent inspection by the Chicago Fire Department.
As recommended at the previous tour, the Fire Safet y Committee is now conducting formal
reviews of all fire investigations. The reviews have resulted in corrective action initiatives to eliminate ignition sources by covering all electrical outlets with Plexiglas, eliminating Styrofoam trays and aluminum juice lids used to trigger a spark to a toilet paper wick.
While there will always be recommendations to continue improving the fire safety and prevention system, the provision continues to be in substantial compliance.
Monitor's Recommendations:
1. Contin ue investigating all fires and fire drills to identify procedural or necessary training improvements.
2. Assure that Cermak management is represent ed on the Interagency Fire Safety Committee that can contribute to assure both patients and staff issues are addressed.
3. Complete the revision process for the Interagency Directive for Fire Safety, Fire Emergency, and Fire Evacuation 64.5.30.0 to assure that they reflect current operations, regulations, and practice. The review needs to be completed at least every two years in accordance with the consent agreement.
72. CCDOC shall develop and implement an evacuation plan for inmates and staff and ensure that comprehensive fire drills are conducted every three months on each shift. CCDOC shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Based on the correspondence referenced in Provision 71 above, division specific Fire Safety and Emergency Plans that include detailed evacuation plans are complete and have been reviewed by the Chicago Fire Department. The Interagency Fire Safety Committee reviews these plans, along with the division safety officers to assure they remain current. The Fire Safety Committee
Page 18 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 19 of 47 PageID #:4692
has implement ed a division specific fire evacuation and emergency key egress box training program to assure that when officers are assigned to a specific division, they are adequately trained in that division's emergency egress key location, response and evacuation procedures.
While the Consent Agreement is not specific as to whether the drill frequency is for the entire complex or within each division, CCDOC conducts one fire drill per month on each shift that includes the movement of inmates for each division. Extinguishers are brought to the drill locations. Videos are available for all fire drills. Written reports are completed and reviewed for non-conformities and corrective action taken including retraining following the drills. This provision continues to be substantially compliant.
Monitor's Assessment:
I did not witness any fire drills during the tour. However, prior to the tour, CCDOC provided a summary of all drills that included the incident report number, date, time, location, and the number of inmates/staff movements made. They also provided a drill analysis of drills conducted in January, 2016, along with copies of the incident reports and assessments. The reports and analysis are substantially improved from the previous tour. The reports highlight non-conformities and the corrective actions to address the cause(s) of the issue.
The Fire Safety Committee is also reviewing all fire investigations including photographs and developing corrective actions based on the review. An example provided was that staff will now account for all milk cartons received and returned in their tier log books.
Monit or's Recommendations:
1. Continue to analyze fire drill videos, reports and summaries. Provide the Monitor with those each month.
73. DFM shall ensure that the Facility has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable fire codes. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures in accordance with City of Chicago Fire Code (13-76-010).
6/ 22/ 15 Concluded by Order of Judge Kendall
74. DFM shall ensure that all fire and life safety equipment is properly maintained and routinely inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the life Safety Equipment.
6/22/15 Concluded by Order of Judge Kendall
Page 19 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 20 of 47 PageID #:4693
75. CCDOC shall continue to 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 em ergency keys.
M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Security and Key Control Interagency Directive was issued effective January 1, 2012. It requires that each Division have a "red" emergency key access box located in the control room. That box contains the key that opens a second box containing all emergency keys for all housing unit doors. The key box is locked and has a security seal that has to be broken to gain access. The policy further requires t hat any time the seal is broken, including during an emergency, the Watch Commander be notified, an incident report written, and an email sent to the Fire Safety Officer to replace the seal. Only a membe r of the Fire Safet y Committee ca n re-seal the box.
All emergency egress keys are color coded and have a two inch glow stick attached to the key ring. Restricted keys are those specifically assigned to designated personnel with the authority of the respective division su perintendent or DFM's Deputy Director/OEIV. These keys are color coded differently than the egress keys. General keys are specifically designated keys for everyday use including the library, classrooms, recreation rooms, etc., and are also color coded. Emergency access keys for DF M shops for Divisions II, IV, V and VI are housed in the Superintendent's office in Division VI. Emergency keys for Divisions VII I, IX, and X are housed in the Superintendent's office in Division IX. Emergency access keys for Division XI o are maintained in the Superintendent's office t here.
The Fire Safety Officer is investigating a color identification code as an addition to the glow sticks.
Monitor's Assessment:
CCDOC reported that t he DFM emergency access boxes are currently not able to be locked. DFM is investigating eliminating these boxes and maintaining emergency keys to their shops in the same eme rgency key box as DFM keys. Accessing emergency keys is included in fire drills. Emergency key t raining is included in t he new officer orientation program. CCDOC has developed an Egress Key Exercise for all correction officers. This is anticipated to be completed by March 16, 2016. One sign -in sheet acknowledges they have completed the exercise on the listed date. The provision continues to be substantially compliant.
Monit or's Recommendations:
Page 20 of 47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 21 of 47 PageID #:4694
1. Establish as part of the fire safety plan a process to at least annually test all emergency keys to assure they can open the corresponding locks.
2. Resolve the storage issue of DFM maintenance shop eme rgency keys.
76. CCDOC 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. CCDOC shall conduct and document random audits to test staff proficiency in performing this task on all shifts, at a minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall communicate with DFM via the Work Order System regarding lock-related issues and maintenance.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
St at us Updat e:
Emergency keys for each division are stored in a secure control room. All keys have been equipped with glow st icks that to allow staff to easily identify a specific key in the case where vision is impaired because of smoke or fire. The Fire Safety Committee explained that on every shift, the officer assigned to the unit or tier inspects all locking mechanisms and reports any issues t hrough the DFM work order syst em. The Fire Safety Co mmittee has implemented an "Egress Key Exercise for each Division on all shifts by all personnel. Egress key accessibility and process are also included as part of the routine unannounced fire drills as described above. The provision continues to be substantially compliant.
M onitor's Assessment:
CCDOC provided a "Damaged Lock Work Order Log'' for January, 2016 identifying 54 damaged locks including malfunctioning lock alerts on the control panel in central control. Work order requests were filed. All but 8 had been completed within 2-4 days upon receipt. There were 25 unsecure lock alerts on the control pane ls from Division XI. Testing of locks is documented are the fire drill reports.
Monitor's Recommendations:
1. Continue testing t he egress key exercise for all divisions during fire drills.
2. Provide evidence that the testing of door locks and what to do if a lock fails is included on the correction officer's training syllabus.
Page 21 of47

Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 22 of 47 PageID #:4695
77. DFM shall develop and implement an annual preventative maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
6/22/15 Concluded by Order of Judge Kendall
78. CCDOC shall implement competency-based testing for staff regarding fire and emergency procedures.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Interagency Directive 64.5.30.0, Fire Safety, Fire Emergency, And Fire Evacuation requires training of sanitation/ safety officers at least annually by or with the approval of the Bureau of Training and Education. CCDOC General Order 24.11.1.0 likewise establishes 4-hour annual training of sanitation officers. CCDOC through the Interagency Fire Safety Committee has implemented the competency based safety officer proficiency examination for all safety officers. There are currently two versions of the test that can be alternated between classes or trainings. The Directive specifically requires fire safety orientation for correction officers during the annual training program in accordance with the current CCDOC General Order. CCDOC has issued division specific Orientation Handbooks. It is the re sponsibility for all CCDOC staff to fully understand expectations and responsibilities for a variety of fire safety and sanitation topics. It includes sections on Safety and Sanitation Inspections of Living Units (General Order #24.9.9.0), Fire Safety (Interagency Directive 64.5.30.0), Egress Keys, Chain of Command, Inmate Count Procedures, and Compound Lockdown Levels Each division has a unique written test for officers to complete after reviewing the divisional handbook.
Monitor's Assessment:
The competency based fire and emergency evacuation safety officer proficiency exam was initiated in August, 2011. The passing score for the exam is 80%. At this tour CCDOC stated that 2016 training will start in March. The provision is substantially compliant. CCDOC provided the Monitor with Power Point presentations for " Fire Safety Training for Supervisors", and " Fire Safety Training" for staff. The presentations are thorough, well organized, and follow the provisions of the General Order for Fire Safety. CCDOC also provided a copy of the proficiency exam .
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Monitor's Recommendations:
1. Continue training and testing until all divisional safety officers for all shifts have completed the training and demonstrated their competency. Provide the Monitor with evidence of training prior to the next tour.
2. Establish a course syllabus (topic outline) for each division's training program and identify the designated trainer responsi ble providing the training.
79. CCDOC shall promptly notify DFM of all electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update :
CCDOC maintains written procedures for prompt submittal of req uests for all work orders requiring maintenance, inclu ding electrical hazards. Specifically for electrica l hazards, both DFM and CCDOC monitor and review the backlog weekly. CCDOC is fully integrated with the DFM "Facility Wizard" work order system. CCDOC uses a "Electrical Hazard Work Order'' tracking log.
Monitor's Assessment:
There is no change from the previous report. Du ring this tour, the Monitor toured the Central Kitchen, housing units in Divisions IV, VI, and VIII. No electrical hazards were observed. CCDOC provided copies of the "Electrical Hazard Work Order Log" for January {6 exposed wires) and February 10 exposed wires). Since the replacement lighting project, the number of work orders for exposed wires and broken fixtures has dropped significantly primarily because inmat es can no longer tamper with the fixtu res. Fire invest igations identified inmates were using the aluminum foil lids from applesauce to create a spark from plugs serving televisions in the housing units. CCDOC is covering them with Plexiglas to reduce access. The provision is substantially compliant.
Monitor's Recommendati ons:
1. No further recommendations.
6/22/15 Concluded by Order of Judge Kendall
81. CCDOC shall ensure that combustibles are controlled and eliminate highly flammable materials throughout the facility and inmate living areas (e.g., inmates' use of paper bags as
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trash receptacles, ripped fire-retardant mattress covers, improvised cell light covers, blanket s on cell floors, and improperly stored and labeled flam mable liquids and other chemicals
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
General Order 24.11.1.1"Sanitation, Fire Health and Life Safety Plans and Reporting" is the CCDOC Master Sanitation Plan. Division specific sanitation plans are revised as appropriate to the General Order. The replacement program for new lighting fixtures has also eliminated inmate's ability to use milk cartons to cover incandescent bulbs.
Inmates are required to maintain all personal belongings and commissary in their personal property bags. Inmates housed in cells are permitted one paper bag per person for trash from commissary that is required to be emptied daily.
CCDOC has developed a "Combustible Material Awareness" PowerPoint presentation to train correction officers that includes photographs of combustibles found during fire investigations.
DFM controls the storage of flammables in their shops by maintaining them in designated secure fire resistant cabinets. As discussed in Provision 73, DFM has completed the color-coded map and inventory of all flammable and hazardous chemicals and provided it to CCDOC division safety officers and Safety Administrator. So within each division, there is an up-to-date inventory of all flammables being stored in that specific division. The inventory is maintained by DFM and is readily available to first responders in case of an emergency.
Monitor's Assessment:
Housing units in Divisions IV, VI, and VIII, assessed during this tour. In Division IV inmates were maintaining an excess of flammable materials in the cells including reading material and paper bags. Inmates were not storing personal belongings in their personal storage bags. This was corrected the next day. Consistent enforcement from tier officers and supervisors to limit the amount of flammable materials within the cells is paramount.
Monitor's Recommendations:
1. Continue enforcement by the tier officer and supervisors to allow one paper bag per cell. All bags in excess should be confiscated including those received with commissary. In dormitories, there should be no paper bags allowed, as trash containers are already provided. All other personal items including shoes, commissary, correspondence,
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books, and magazines must be required to be stored in the inmate's personal property bag.
2. Investigate non-flammable alternatives for delivering commissary items.
82. CCDOC 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.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Updat e:
The Interagency Directive for Fire Safety, Fire Emergency, and Fire Evacuation, 64.5.30.0, was authorized effective August, 2011. The policy establ ishes that all CCDOC emp loyees must receive training and become well-versed in the fire safety, emergency, and evacuation plans of the department and its divisions. This includes safety officers. (Note: In the divisions there are designated and trained "Safety/Sanitat ion Officers" that are equivalent to the term "fire safety officers" identified in the provision.) Further, the policy explains that "Communication among and between CCDOC, Cermak, and CCDFM employees is key in assuring a safe facility, and all shall work together to implement this directive."
The Interagency Directive requires the designat ion and trai ning for all CCDOC divisional safety/sanitation officers for each division at least annually. The training must be provided by or with the approval ofthe Cook County Sheriff's Office Training Institute, through the CCDOC Safety Office and the Chicago Fire Department, and in accordance with a written course syllabus to be reviewed annually by the Fire Safety Committee.
The training of safety/sanitation officers is currently provided by the CCDOC designated Safety Administrator, using the video of one of the courses previously provided by t he Chicago Fire Department. Following the training, safety officers are required to pass a written proficiency examination. CCDOC has also developed a "Fire Extinguisher Training" PowerPoint that is thorough tutorial on the types of extinguishers, operation, and firefighting ru les.
Monitor' s Assessment:
Training of annual safety/sanitation officers is expected to start in March for 2016. Demonstration of their ability to effectively use a fire extinguisher is included in the regular fire drills conducted in each division each month.
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As explained earlier in this report, the divisional orientation handbooks for divisional safety officers are now complete and issued. On future tours, I will continue to monitor safety officer knowledge by wit nessing drills and questioning housing officers. This provision continues to be in substantial compliance. Monit or's Recommendations: 1. Provide the Monitor with a current roster of safety officers from each division who are
current in their training to assure that all shifts are covered. 2. The Safety Administrato r needs to assure that all designated Safety Officers assigned within
the divisions have received the annual training required in the Interagency Directive. Sho uld a Safety Officer be transferred or leave CCDOC, the superintendent, prior to the transfer or leave shall provide the name of t he replacement Safety Officer to the Safety Administrator. 3. Est ablish a process within each division that assures the superintendent that there is always a trained Safety Officer within their division on all shifts at all t imes. PROVISION: G. SANITATION AND ENVIRONM ENTAL CONDITIONS 83. Sanitation and Maintenance of Facilities a. DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate maintenance of the Facility. 6/22/15 Concluded by Order of Judge Kendall 83. Sanitation and Maintenance of Facilities
b. CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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. M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
The CCDOC General Order 24.11.1.0, Divisional Sanitation Plan became effective in February, 2012 and was revised to CCDOC General Order 24.11.1.1, "Sanitation, Fire, Health, and Life Safety Plans and Reporting." This order is a companion order with General Order 24.9.9.0, Safety and Sanitation of living Units which became effective December, 2011 and currently is under revision. Both Order revisions reflect improved practice and include specific sanitation schedules for all housing and common areas of the divisions and require documented housekeeping completion logs, inspection reports, deficiency plan for corrective action and requisition procedures for cleaning supplies.
Division designated sanitation officers for each division has are trained by the CCDOC Sanitarians on safe and effective cleaning and disinfecting procedures. In the General Order, Watch Commanders are responsible for reviewing the completed Daily Inspection Forms from each of the living units and submitting a weekly summary report. The Support Services Superintendent and Sanitarians receive and review the weekly summary of the sanitation log from each of the divisions. The divisional sanitation plans mandate that sanitation officers observe the cleaning and disinfection of cells, dayrooms, toilets and shower facilities. Since the divisional sanitation plans became effective, the Sanitarians continue to conduct unannounced inspections of living units within all divisions.
CCDOC has implemented an incentive for housing unit cleanliness and order by providing microwave ovens to those living units where the rules are being followed. This process establishes accountability from both inmates and officers to improve and maintain the level of cleanliness and order of the living units as well as common areas including classrooms, maintenance closets, and tunnels. Improvement in cleanliness in those housing units where microwaves have been provided is generally significant when compared to those units where they are not available.
Cermak Environmental Services has developed a written policy with input from CCDOC that establishes procedures for cleaning and disinfection of all areas for medical and mental health inmates and each of the division specific dispensaries. Its purpose as stated is to, "To ensure through collaborative departmental efforts of sanitation, prevention, maintenance, and education that all areas under Cermak Health Serv ices" (CHS) authority shall be maintained clean, disinfected, well organized, and in good repair." It establishes formal housekeeping procedures, schedule, and expectations for the building service workers responsible for completing the all cleaning and disinfection. It includes a weekly "monitoring" program conducted by building services supervisors to be submitted to the Environmental Services
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Director. Environmental Services has provided training of the building service workers and supervisors.
Monitor's Assessment:
On this tour the Monitor assessed housing units in Divisions IV, VI, VIII, and X. The housing tiers in all Divisions visited were maintained clean with the exception of Division IV. There, the inmates had recently been relocated there from Divisions Ill and XVII, which were closed. A revisit completed the next day demonstrated signif icantly improved housekeeping and controlled commissary and personal items.
Inmates were maintaining personal property in their assigned bags. Trash bags are limited to one bag per person per cell. The shower areas in Division VIII were maintained very clean with no build-up of soap scum as found in previous visits. CCDOC purchased power washers which are used at least weekly to deep clean the shower walls and floors.
Monitor's Recommendations:
1. Continue to regularly monitor housekeeping in all housing areas.
83. Sanitation and Maintenance of Facilities
c. DFM 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.
1. 6/22/15 Concluded by Order Judge
83. Sanitation and Maintenance of Facilities
d. CCDOC shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing. lighting, and ventilation problems.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update: The DFM "Facility Wiza rd" work order tracking system interface has been operational at both CCDOC and Cermak since April, 2012. General Order 24.9.9.0 esta blished an inspection protocol for sanitation and living unit officer to identify and initiate work order requests for DFM, as appropriate. The food service contractor has access to submit work order requests through Support Services. The CCDOC Sanitarians can also submit work order requests. The Sanitarians have also created a Power Point presentation for training living unit officers demonstrating what constitutes a needed plumbing, electrical and emergency issues.
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As a result, work orders from CCDOC staff can provide work orders as soon as they id entify issues. The use of the 24 hour hotline for emergency repairs assures that emergency maintenance repairs are forwarded to DFM quickly and typically respond to these within minutes. Monitor's Assessment: While visiting numerous housing units in several divisions, the Monitor noted that whenever a maintenance issue was identified, the commande r or sanitation officer was able to document that a work order request had been su bmitted. Each division maintains a spreadsheet listing the outstanding work orders. The spreadsheet is updated at least weekly. Universally, housing officers and supervisors stated they are pleased with the timely response from DFM to complete repairs. The provision cont inues to be in substantial compliance. Monitor's Recommendations: 1. No further recommendations. 83. Sanitation and Maintenance of Facilities
e. DFM shall ensure adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on and annual basis for non-automated systems. 6/22/15 Concluded by Order Judge Kendall 83. Sanitation and Maintenance of Facilities f. CCDOC shall notify DFM of any visible obstructions to the ventilation system. March, 201 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: As discussed above, DFM staff clean and/or replace blocked or dirty vents based on CCDOC staff submitting work orders. When tier officers identify blocked vents, a work order is submitted to DFM through the work order system.
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Monitor's Assessment:
On this tour the Monitor identified only one blocked vents and none that needed cleaning to assure adequate air flow. The Sanitation Plan requires living unit officers to identify and notify DFM should vents become blocked. Blocked vents are no longer an issue within any CCDOC division. This provision continues to be in substantial compliance . Monitor's Recommendations: 1. No further recommendations.
83. Sanitation and Maintenance of Facilities g. Cook County shall ensure adequate lighting in all inmate housing and work areas.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: DFM maintains the responsibility for assuring adequate lighting throughout the CCDOC complex. In 2013 they completed a capital project to replace or retrofit all lighting and light fixtures with secure fixtures that would prevent inmate abuse and improve energy efficiency within the living units within all divisions. Lighting in housing and work areas is no longer an issue withi n all of CCDOC. Fixtures requiring the use of unprotected Incandescent bulbs are no longer used in inmate cells.
Monitor's Assessment: There is no change from the previous report. According to CCDOC staff there has been very few issues with lighting. This provision continues to be in substantial compliance. Monitor's Recommendation:
1. No further recommendations. 83. Sanitation and Maintenance of Facilities
h. CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.
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M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
St atus Update:
CCDOC maintains a contract for pest control services for all facilities with the exception of Cermak. Cermak maintains a separate contract their facility. The contract requires the pest control technician be onsite 5.5 hours per day. They have provided CCDOC a map showing the location of all traps, and provide a comprehensive inspection and follow an "Integrated Pest Management" approach. The contractor is required to complete a floor drain cleaning procedure a minimum of twice pe r year to prevent insect eggs and larvae from developing, and provide a 24 hour response time for complaint response. They provide a quarterly trend report, tracking insect and rodent activity for all divisions, along with electronic reports of their inspections and any recommendations for improved sanitation and/or maintenance re pairs.
CCDOC maintains a "pest control hotline" for office rs to report any pest activity. Steps to prevent pest issues and infestations are reinforced at the training academy for all correction officers.
Monitor's Assessment:
CCDOC provided a copy of the fourth quarter Pest Identification summary including charts showing bot h interior and exterio r catches. The most recent report noted rodents are being captured before they penetrate the structures. Specifically the number of exterior captures was nearly double the number of interior catches. Further there was a SO% reduction in interior rodent captures compared with the third quarter of 2015. The fourth quarter is the season of highest infiltrations just prior to winter.
There were no rodent captures within the Central Kitchen and only one in the Division XI kitchen. For the quarter there were 50 rodent catches including 27 exterior and 23 interior. 13 of the interior cat ches were in Division I, which is now closed. Insect activity for the quarter was sporadic and controlled w ith improved cleanliness and not allowing inmates to maintain food from meals within t heir cells or dormitories.
In summa ry, CCDOC Sanit arians provide a summary report to management and meet regularly with the contractor to modify their schedu le and address hot spots. This provision continues to be in substantial compliance.
Monitor's Recommendations:
1. Continue to provide pest control quarterly reports.
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83. Sanitation and Maintenance of Facilities

i. CCDOC shall ensure t hat all inmates have access to needed hygiene supplies.

M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

Status Update:

CCDOC implemented General Order 24.11.6 with an effective date of March, 2014. It requires that upon intake, employees shall issue inmate basic hygiene supplies including soap, toothpaste, toothbrushes, and as appropriate sanit ary pads. Weekly, the sanitation officer makes rounds to each housing unit to replenish inmate supplies of tooth brushes, tooth paste, and toilet paper. Inmates needing additional supplies during the week only need to notify the housing unit officer on any shift. CCDOC maintain t he logs, which will eventually be electronic so they can monitor excess hoarding of supplies. The logs demonstrate that t he inmat e received needed supplies.

Monitor's Assessment:

The Monitor observed the distribution for females in Division IV during the tour. CCDOC also provided copies of the logs that are being utilized. They demonstrate that inmate hygiene supplies are received by t he inmates. On this tour I did not receive any complaints from inmates nor see any grievances about the lack of needed hygiene supplies. This provision is in substantial compliance.

Monitor's Recommendations:

1.

No further recommendations.

83. Sanitation and Maintenance of Facilities

j. CCDOC shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction standards. CCDOC 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.

March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

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Status Update:
Biohazardous waste from Cermak's medical facility and the medical and/ or dental clinics in the divisions is the responsibility of Cermak, not CCDOC. Biohazardous waste in Cermak is secu rely stored and placed in red bags for daily pick up by designated Cermak staff. Cermak maintains a contract for collection and final disposal of the waste.
For biohazardous waste from living units or laundry, each division maintains a supply of biohazardous spill kit s within the security office and the sanitation supply rooms. They are replaced as needed through Support Services. CCDOC policy does not permit inmates to clean bio-hazardous spills. A new blood-borne Pathogen Decontamination General Order was issued in January, 2013. Support Services Sanitarian created a Power Point training presentation for biohazardous waste handling and cleanup that is now provided to all sanit ation officers. There is a written syllabus for blood-borne Pathogen clean-up training. Cermak teaches the blood-borne pathogen training at the Academy and during in-service.
Monitor's Assessment:
On this tou r, the Monitor observed the supply of spill kits in the sanitation room of Division VI. The kits include personal protective equipment (PPE) for response staff has well as clean-up supplies. The warehouse maintains a supplemental supp ly to replenish the divisional supplies. CCDOC staff has trained all sanitation officers on all shifts the safe response procedures.
Monitor's Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
k. DFM shall develop a policy on hazardous materials, in accordance with generally accepted correctional standards, and insure that all DFM staff is properly trained on the procedure.
6/22/15 Concluded by Order of Judge Kendall
83. Sanitation and Maintenance of Facilities I. CCDOC shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
CCDOC dilutes concentrated che micals following the chemical manufacturer's specifications from the central supply located in Division V and distributes them daily to the divisions as request ed. By centrally controlling the dilution and following the chemical manufacturer's directions, the divisions only receive properly dilut ed cleaning and disinfecting chemicals needed for routine cleaning and san itizing of floors, toilets, lavatories, showers, etc. and effective cleaning and sanitizing surfaces from biohazard spills.
The chemicals include a general purpose clea ner, a disinfectant, glass cleaner; stainless-steel cleaner, deodorizer, and bleach along with a supply of spray bottles and labels. Only the floor care team has access to chemicals used for floor care including floor stripper, floor wax, floor cleaner, and floor sanitizer Also availab le from the CCDOC warehouse are mop heads, mop sticks, vacuum, power washer brooms, dust pans and squeegees, along with buckets brushes, Tyvec suits, vinyl gloves, garbage bags and eyewash stations.
Training for inmates and CCDOC sanit ation officers on the safe and effective use of cleaning is taught by the Sanitarians. Training is provided to those assigned the responsibility of cleaning cells, showers, toilet facilities, dayrooms, classrooms, tunnels, and all administrative areas. These are two-hour classes daily, for one week. Each person that takes the class and successfully passes a written test is presented with a certificate of completion.
"Sanitation kits" have been distributed to each operating living unit to be used for inmate mattress cleaning and daily cleaning done by inmates. The crates include one spray bottle of GP Cleaner, a spray bottle of disinfect ant, two brushes (one for touch surfaces and one for toilets), fou r rags and an instruction card. Kits are now included in the count clearing process and the tier officer is responsible to assure inmates do not misuse the chemicals. The sanitation officer on the llpm to 7am shift is responsible to collect and restock the kits.
Monit or's Assessment:
There has been no change since the previous report. This provision continues to be in substantial compliance.
Monit or's Recommendations: 1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
m. CCDOC shall inspect and replace as often as needed all frayed and cracked mattresses. CCDOC shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. CCDOC shall ensure that mattresses are properly sanitized between uses.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
St atus Update:
Mattresses are replaced as needed throughout the divisions when they become no longer cleanable or beyond repair. Each division maintains a small surplus of mattresses and more are available from Central Supply. If medically ordered, Inmates in Cermak may be provided pillows and pillowcases. Each division has a designated clothing and bedding storeroom and has established procedures to inspect, clean, disinfect , and repair or replace mattresses before they are provided to incoming inmates. Each room has separate areas for storage of clean and soiled mattresses. The mattress is removed from the cell when an inmate is moved or discharged and taken to the designat ed storeroom within the respective division for cleaning and disinfection using a general purpose cleaner and disinfectant. The mattress is allowed airdry and returned to the cell or dormitory for use. Inmates are also permitted clean their mattress during scheduled daily cleaning utilizing the sanitation kits described above.
Hospital mattresses within Cermak are cleaned and disinfected within the cell or dormitory anytime an inmate is transferred or discharged. Cermak's sanitation policy, formally establishes the procedure for cleaning and disinfecting them.
Monitor's Assessment:
On this tour, all mattresses observed were well maintained with no tears or excessive wear. The Monitor did not receive any complaints from inmates regarding mattress issues. Staff reported the warehouse maintains an adequate supply of replacement mattresses.
Monitor's Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
n. CCDOC shall ensure adequate control and observation of all housing units, including distribution and collection of razors and cleaning supplies. All cleaning tools and
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hazardous chemical shall be removed from housing areas after use.
M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
St atus Updat e:
CCDOC has established General Order 24.11.7.0, Inmate Razor Distribution Effective March, 2014. Razors used throughout CCDOC are color coded by division. The CCDOC Assistant Executive Director (AED} of Special Projects is responsible for maintaining inventory of inmate disposable razo rs and assigning designated staff to issue razors to each division. Each division Watch Commander is required to assure accuracy of the inventory and designate employees on each shift to verify the number of disposable razors on hand before distribution and upon their return form the inmates. Divisions are issued two biohazard waste containers with disposable plastic liners; one used to transport unused razors and one for collecting and returning used razors. The date and amount of razors are tracked in a "Disposable Razor Logbook" signed by the officer accepting the razors. Used razors are placed in the red biohazard container designated for "used" razors and returned to the AED for Special Projects office for safe disposal. No razors are maintained in the housing tiers or dormitories. All razors, used and unused, are audited daily to assure complete retrieval. If a discrepancy is identified, an incident report is generated. Razors are available for use by inmates on the 11pm to 7am shift Monday through Friday with the exception of holidays.
Monitor's Assessment:
The Monitor reviewed the missing detainee razor blades report for January and February, 2016. There were two incidents. Incident reports were completed for both. One involved self-harm by an inmate; the blade was collected. The other was t he recovery of a missing blade. There were no reports of missing blades.
The provision continues to be in substantial compliance.
Monitor's Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
o. CCDOC shall ensure that Facility Sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility Sanitarians should also have training on and access to testing equipment to ensure
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sanitary conditions.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC employs two full time Registered Sanitarians, who report to the Superintendent of Support Services. Both Sanitarians are active participants for all areas of the consent agreement involving environmental and safety issues including chemical control, sanitation, laundry, food service, and fire and life safety. They actively participate in the review and revision of General Orders for these areas, along with developing and providing specific training programs to correction and civilian staff, and inmates. CCDOC provides them with and they regularly use measuring and testing equipment to monitor sanitation, temperatures, etc. They continue to research specific environmental issues such as pest control trends, food service, laundry, sanitation, maintenance, biohazardous materials, etc. They conduct independent sanitation audits, both for corrections and Cermak whi ch has resulted in modification and improvements to training progra ms, enhanced follow up work and objective counsel with both corrections and coordinating efforts with Department of Facilities Management.
They meet regularly with the contractor for food service, pest control, division superintendents, CCDOC management, Cermak, and DFM to assess and resolve issues. As part of their inspections, they regularly speak with both inmates and staff to identify issues that need resolution . They have an integral role in the implementation and monitoring of several CCDOC policies relative to sanitation and provide direction to the divisional sanitation officers. They have trained all divisional sanitation officers on correct cleaning procedures to assure continuing effective cleaning and sanitation. CCDOC is fortunate to have selected two Sanitarians who understand institutional environmental health, along with unique correctional issues and that are able to interpret and find solutions to protect the safety and health of both inmates and fellow employees.
Monitor's Assessment:
CCDOC continues to maintain two environmental health positions. One new Sanitarian was recently hired due to a resignation. They regularly monitor cleanliness in inmate housing, pest control, laundry, food service, fire safety issues, and work closely with Cermak Environmental Services on environmental issues there. They speak with inmates and correction officers helping them understand the public health reasons for specific policies and procedures, along with the impact of following them correctly. Their commitment and their technical and communication skills have added considerable value to solve sanitation and safety issues in the divisions. This provision remains in substantial compliance.
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Monitor's Recommendations:
1. No further recommendations.
PROVISION: G. SANITATION AND ENVIRONMENTAL CONDITIONS
84. Sanitary laundry Procedures
a. CCOOC shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted correctional standards. To limit the spread of communicable disease, CCDOC shall ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and dry.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC operates laundries in Division Ill, V, and Division IX. The Division V laundry is the main laundry for the complex. The Division Ill laundry handles the laundry for Division IV, while that laundry is undergoing renovation including equipment replacement. The Division IX laundry is used as a back-up in case of equipment breakdowns in Divisions Ill and V. The food service contractor operates a separate laundry to clean inmate worker uniforms and kitchen laundry. No laundry is taken off-site.
CCDOC authorized General Order 24.11.3.0 effective March 7, 2014. It establishes the responsibilities assigned to the Laundry Unit Watch Commander and outlines the necessary training requirements for employees and inmates assigned to the laundry units addressing safe sorting, washing, drying, and folding procedures and appropriate sanitation precautions necessary to be taken to assure that clean laundry is never cross-contaminated with soiled laundry. Th e Laundry Watch Commander, in turn, is responsible to train inmate workers on the procedure, sanitation, and the use of personal protective equipment (PPE).
The policy requires all inmates to exchange soiled clothing and linen and strictly prohibits inmates from washing and drying clothing or linen contrary to the provisions of the General Order. Laundry is collected from inmates twice each week on a posted schedule. Once cleaned, it is returned typically within the same shift from when it was collected . Living unit officers who observe clothing and linen being washed by inmates are expected to confiscate all such items and issue clean, dry clothing and linens and initiate an Inmate Disciplinary Report.
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Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 39 of 47 PageID #:4712
The Central laundry in Division V consists offive 150-lb Unimac washe rs and five 170-lb Unimac dryers. The Division Ill laundry consists of three Speed Queen 40 lb. washers and two 40 lb. dryers. The kitchen has one washer and one dryer.
Laundry chemicals used in all washers, including bleach, detergent and sour, are electronically dispensed. Laundry chemicals used are currently purchased from Ecolab. They include Ecostar Builder C detergent, Ecostar Destainer {Bleach), and Ecostar Sour (a pH adjusting chemical) to prevent skin irritation and fabric browning. Safety Data Sheets {SDSs) for all laundry chemicals are posted, maintained up-to-date and readily available. At all laundries bins used to transport clothing, linens, and blankets to and the divisions are cleaned and disinfected with Clorox disinfecting wipes before clean laundry is placed in them.
Weekly, CCDOC weekly tracks the amount of personal clothing sent to the laundry. The reports are provided at each Superintendent's accountability meeting each week. The laundry supervisor records the amount by weight of laundry received from each division including linens, uniforms, and personal laundry.
Monitor's Assessment:
The inmate personal laundry trend report from November, 2015 through February, 2016 continues to demonstrate increasing use in all divisions CCDOC's inmate cultu re for many years has been that personal laundry is often misplaced, lost, and never returned or if returned it is wet, and late and sometimes missing clothing. The use of the laundry loops has helped reassure inmates. The trend report shows inmates have more confidence in their personal clothing being returned clean, dry and on schedule. This provision continues to be in substantial compliance.
Monitor's Recommendat ions:
1. No further recommendations.
84. Sanitary Laundry Procedures
b. CCDOC shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas
M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
CCDOC Genera l Order 24.11.3.0 prohibits inmates from washing and drying clothing or linen other than through the CCDOC's laundries. It requires Living Unit Officers to confiscate clothing or linens being washed by inmates and issuance of clean, dry clothing and/or linen and issuance of an Inmate Disciplinary Report.
The policy and practice require uniform, and towel be exchanged twice each week, sheets once per week and blankets exchanged once per month. Personal cloth ing is collected t wice per week from all housing units and is returned the same day on the shift from which it was collected. A laundry schedule is posted in each living unit, and each division is required to include in its weekly Summary Report specifically which living units did not receive linen exchange as req uired by the policy. All laundry is washed using electronically dispensed detergent. White clothing also is wash ed with bleach. All clothing, linens and blankets are thoroughly dried at a high temperature.
Monitor's Assessment:
There is no change from the previous report. I observed the posted laundry schedule in each housing unit of each division that I toured. The laundry operates on two shifts daily to assure time ly return of clean laundry. CCDOC has created posters explaining w hy all clothing needs to be cleaned and disinfected through the laundry, developed videos for the inmat e televisions, and have taken designated inmates to visit t he laundry to see firsthan d the laundry process.
Monitor's Recommendations:
1. Continue to monitor laundry usage for each division and report changes to management as necessary. Provide the Monitor with quarterly trend reports.
84. Sanitary laundry Procedures
c. CCDOC shall train staff and educate inmates regarding laundry sanitation policies.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Inmate laundry worke rs assigned to t he laundry are trained as to their responsibilities by office rs assigned to General Order 24.11.3.0. The Order states the training includes both classroom and hands-on instruction as to the responsibilities, acceptable laundry sanitation practices and the use of laun dry equipment, chemicals and the use personal protective equipment (PPE).
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Monitor's Assessment: The Monitor did not tour the laundries on this visit. This provision continues to be substantial compliance. Monitor's Recommendations: 1. No further recommendations. 84. Sanitary Laundry Procedures
d. CCOOC 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. March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: Clean inmate laundry is returned to the division from which it came in bins that are sanitized with a disinfecting bleach wipe before clean clot hing, uniforms, bedding etc. are placed in the carts. All carts are thoroughly wiped by laundry workers and allowed to air dry. There are designated areas wit hin each laundry that separate dirty laundry bins from those that have been cleaned and sanitized. Designated tab les in each laundry are only used to sort and fold clean laundry. The tables are cleaned and disinfected at the beginning and at the end of each shift. Monitor's Assessment: The Monitor did not tour th e laun dries on t his visit. Staff reported there are no changes since the previous tour. The provision continues to be substantially compliant. Monitor's Recommendations: 1. No further recommendations. 84. Sanitary Laundry Procedures e. CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures. M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
General Order 24.11.3.0 specifically prohibits inmates from washing and drying clothing, towels, or linen except through the designated CCDOC laundry. Further as discussed in Provision 84.a, living unit officers are required to confiscate any clothing or linen items being washed and replace them with clean dry clothing and/or linen. Inmate's uniform, personal clothing, linens and blankets are collected twice each week in each housing unit in every division as prominently posted in the unit.
CCDOC provides laundry loops for inmate personal clothing and assists inmates in their correct use to help assure that their clothing will not get lost. Personal laundry is returned to the inmate typically on the same shift of the same day it was collected. CCDOC has also removed laundry soap from the commissary order form to preclude inmates from doing their own laundry... As discussed in 84.a, CCDOC continues to track by weight the amount of personal clothing submitted.
Monitor's Assessment:
Use of the CCDOC laundry system for uniforms, towels, linens, and blankets is for the most part universally accepted and practiced. A review of the laundry trend reports demonstrates that the inmate culture to not use the laundry is clearly changing. CCDOC has posted easy to understand posters, schedules, and shown videos on televisions. On this tour the Monitor observed very little personal clothing drying in cells or dayrooms. The provision continues to be substantially compliant
Monitor's Recommendations:
1. Continue to regularly monitor and track the use of the laundry and as discussed above include a discussion and expect ations as regular agenda topic at Divisional Superintendent's accountability meetings.
85. Food Service
a. CCDOC shall ensure that all food service at the Facility is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures.
M arch, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC maintains a contract with CBM Premier Management to provide meals to all inmates. CBM utilizes the central kitchen for all food preparation. The Division XI kitchen is only utilized
Page 42 of47

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for the hot meal for inmates housed there. Equipment and areas in both kitchens continues to be well maintained and clean. Two new steam cookers are installed at the main kitchen and should be operational in April.
CBM maintains responsibility for sanitation and maintenance of all equipment. They have two maintenance technicians who work on a schedule that allows for weekend coverage as needed. Area and equipment cleaning and sanitation are done by inmate workers who are trained and supervised by CBM employees. CCDOC officers assigned to the kitchen provide security.
Together CCDOC, and CBM have improved the process to assure that inmates receive the hot meals are received hot by significantly reducing the delivery time for transporting the food from the Central Kitchen to all divisions. CCDOC Sanitarians regularly monitor and record food temperatures at the time of delivery to compare it with recorded temperatures taken as the food is placed in trays in the kitchens. CCDOC Sanitarians, kitchen security officers and Support Services Superintendent meet weekly with CBM to review grievances and address both operational and logistic issues. A meeting summary is produced following each meeting. It includes a running list of outstanding issues including resolutions.
CBM regularly measures and records food temperatures as food is placed in trays and as it leaves the kitchen to the divisions. Division staff also record food temperatures at delivery to the inmates.
CCDOC Sanitarians conduct unannounced inspections of both food service kitchens to assure that meals prepared are safe and that kitchens operate in accordance with Illinois Food Code regulations. They also review the regulatory inspections of both kitchens completed by the City of Chicago Health Department and meet with CBM to assure any violations are corrected ...
Monitor's Assessment:
CBM has and continues to work closely with CCDOC Support Services staff to identify and resolve issues related to food service. Following the last tour CCDOC and CBM did a thorough analysis of the transportation and delivery process to address numerous complaints about hot meals being served cold. The result was a 30 to 45 minute reduction in delivery time. During this tour I received no complaints about food temperature. The Monitor continues to suggest that CBM regularly receive feedback from inmates to improved processes.
CBM provide cold meals on reusable trays and eliminated Styrofoam trays which inmat es would save and use to block air vents. Styrofoam trays are only used for segregation and court meals. Trays are collected following each meal service and returned to the kitchen for washing and sanitizing. Separate reusable compartmented style trays are used for serving the hot meal.
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Case: 1:10-cv-02946 Document #: 316 Filed: 04/14/16 Page 44 of 47 PageID #:4717
CBM has developed and implement ed documented employee and inmate worker training programs, an internal inspection program, temperature monitoring program, formal staffing plans for employees and detainee workers, weekly cleaning schedules, a number of Standard Operating Procedures (SOPs), security standard and procedures, inmate kitchen worker orientation checklist, health screening, emergency evacuation plan in compliance with the fire safety committee, and an emergency food service contingency plan.
On this tour both kitchens including storage rooms, refrigerators, freezers, loading docks were maintained clean and well organized. Inmates were appropriately supervised and working efficiently.
This provision continues to be in substantial compliance.
M onitor's Recommendations:
1. No fu rt her recommendations pertaining to the provision.
85. Food Service
b. CCDOC shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
St atus Updat e:
All CBM management employees are Certified Food Safety Managers through the accredited Serv-Safe program and documentation is maintained showing that "Food Manager Certificat ion" certificates that are current. CBM has established written job descriptions for all employee positions that include responsibilities and tasks. CBM provides orientation training to inmates daily. Inmates are required to sign an attendance sheet that is maintained by CBM management. A check list is used to assure inmates understand the food safety requirements pertaining to their assigned responsibilities. CCDOC Sanitarians developed an inmate training video that addresses health issues and personal hygiene that is shown to all potential inmate workers before they are assigned to work in the kitchens.
Monitor's Assessment:
There is no change since the previous report. The State of Illinois requires food service managers to successfully complete a "State" approved food manager certification program. Six CBM management employees are currently certified by the State of Illinois. Eleven CBM
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employees have successfully complet ed the Serv-Safe Food M anager Certification. Certificates for those employees are posted in t he employee break room.
This provision remains in substantia l compliance.
Monitors Recommendations:
1. No further recommendations.
85. Food Service
c. CCDOC shall ensure that the Central Kitchen and Division XI kitchen are staffed with a sufficient number of appropriately supervised and trained personnel.
March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CBM maintains a staff of 57 full or part time employees with schedules to assure adequate coverage for all mea ls daily and including weekdays. They have a written food service staffing guide that outlines the starting and ending times for all employees. The kitchen operates two shifts, as cold meals are prepared in advance of their serving, and maintained refrigerated as necessary. Additionally they utilize approximately 230 detainees scheduled over t hree, six or eight hour sh ifts just in the central kitchen t o work in a variety of food service operations including preparation, fi lling meal t rays, cleaning, warewashing, etc. Division XI inmate workers from that Division are assigned to work in that Division's kitchen to prepare and tray the dinner hot meal. The contractor is responsible for t raining and supervising their employees and the inmate workers assigned to the kitchen.
CCDOC provides inmate wo rkers as needed. They also provide security officers for safety supervision of inmat es and for tool control and st aff to transport and serve meals to the divisions. CCDOC provides t he security training of kitchen staff.
Monitor's Assessment :
There is no change from the previous report. Support Se rvices staff stated that CBM continues to maintain adequate number of qualified, trained and workforce at all times to assure timely prepa ration and service of meals to detainees. Regular weekly meetings between CCDOC Support Division including the staff sanitarians, security staff, CCDOC management and CBM leadership include discussions of adequate staffing as well as other issues. The provision remains in substantial compliance.
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M onitor's Recommendations:
1. No further recommendations.
85. Food Service
D. CCDOC shall ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are appropriately cleaned and sanitized.
March, 2016 COM PLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Updat e:
Equipment, utensils, and food preparation areas including floors, walls, and facilities are maintained clean through shift and daily cleaning schedules established by CBM. They have created and implemented written cleaning procedures for all equipment in accordance with the equipment manufacturer's specifications and a cleaning checklist/log for both kitchens along with a daily and weekly cleaning schedule for each room and the equipment in the kitchens such as the meat/packing room, wet room, bakery/packing room, dock, dry storage areas. It identifies what is to be cleaned, the frequency for cleaning and who is responsible for the cleaning. CBM trains, uses, and supe rvises inmate workers to clean and sanitize all areas identified on the cleaning schedule. Once completed, the supervisor initials the log and the records are maintained and are available for the Sanitarians to review during their inspections. The trays used for all meals are washed and sanitized after each meal and the cleaned trays are stored on appropriately designed racks t hat allow water to drain and the trays to dry between uses. CCDOC has two operating warewashers that are capable of cleaning and sanitizing equipment and utensils.
M onitor's Assessment:
CBM continues to maintain all food service areas, equipment and utensils exceptionally clean. The kitchens are maintained as a model for institutional food service facilities. This includes walk-in refrigerators, freezers, dry storage areas, food preparation and asse mbly rooms, warewashing, carts used to transport food to the divisions, offices and laundry Both inmate workers and emp loyees understand the expectation for cleanliness and disinfection of surfaces. Management and supervisors expect and demand excellence from employees and inmate workers. Inmate workers are quickly replaced when they do not perform. CCDOC is in the process of replacing both warewashers due to age and frequent repairs issues.
This provision remains in substantia l compliance.
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Monitor's Recommendations: 1. No further recommendations. 85. Food Service
e. CCDOC 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. March, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: The temperature monitoring and recording program implemented by CBM and monitored regularly by CCDOC Sanitarians demonstrates that this provision remains in substantial compliance. CBM has implemented an appropriate monitoring program to measure, record, and maintains logs for all refrigerators, freezers, and warewasher equipment. Logs ofthe temperature measurements are not only reviewed by CBM management, but also provided to the CCDOC Sanitarians weekly. Any required maintenance deemed necessary as a result of monitoring is completed by trained CBM maintenance workers. CCDOC Support Services Sanitarians, as well as regulatory inspectors continue to do independent monitoring of temperatures during their routine during unannounced inspections of both kitchens. Monitor's Assessment: There is no change from the previous report. I again reviewed temperature logs for several refrigerators and freezers in the central kitchen during this tour. The monitoring logs were current, legible and reviewed by management. This provision remains in substantial compliance. Monitor's Recommendations: 1. No further recommendations.
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 Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 1 of 100 PageID #:5000

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

UNITED STATES OF AMERICA,

Plaintiff,

v.

COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),

No.lO C 2946 Judge Virginia Kendall

Defendants,

Monitor Jeffrey L. Metzner, M.D.'s Report No. 12

Jeffrey L. Metzner, M.D., P.C. 3300 East First Avenue Suite 590 Denver, CO E-mail: ,Jeffrey.metzner@ucdenver.edu

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JEFFREY L. METZNER, M.D., P.C. 3300 EAST FIRST AVENUE SUITE590 DENVER, COLORADO
TELEPHONE (303) 355-6842 FACSIMTLE (303) 322-2155

MEMORANDUM

TO:
FROM: DATE: RE:

Donald J. Pechous, Esq. Cook County State's Attorney's Office
500 Richard J. Daley Center
Chicago, Illinois 60610
Paul O'Grady, Esq. Peterson Johnson& Murray 233 South Wacker, 84th Floor Chicago, Illinois 60606
Kerry Dean, Esq. U.S. Department of Justice P.O. Box 66400 Washington, DC 20035-6400
Jeffrey L. Metzner, M.D. May 19,2016 U.S.A. v Cook County, et al No. lOC2946

I have completed my assessment of the mental health services offered at the Cook County Department ofCorrections (CCDOC) through Cermak Health Services ofCook County (CHSCC). I site visited CCDOC from April18-22, 2016. This fmal report incorporates suggestions made by the parties regarding my draft report.
Sources of information utilized in compiling this report included the following:
1. review of documents provided in response to my written request for pre-site information, which included the following documents: a. status update to the Agreed Order, b. Mental Health Quality Improvement Committee meeting minutes, c. Suicide Prevention Committee meeting minutes, d. numerous mental healthcare quality improvement studies, e. root cause analysis reports re: recent suicides within CCDOC,
2. interviews with many inmates in group settings in Division 8 (RTU), Division X,

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Re: Mental Health Services at CCDOC
USA v Cook County, et a!.
Page 2 of9
3. observation of treatment activities in Division 8, 4. information obtained from key administrative and clinical staffthat included, but was not
limited to, the following persons:
a. Jay Shannon, M.D. (CEO, Cook County Health and Hospitals System), b. Krishna Das, M.D. (Chief Quality Officer), c. Claudia Fegan, M.D. (Executive Medical Director), d. Agnes Therady, R.N. (Executive Nursing Director), e. Christopher Wurth (Chief Operating Officer Hospital Based Services), f. Connie Mennella, M.D. (Chair, Department of Correctional Health Services), g. Nneka Jones, Psy.D. (First Assistant Executive Director), h. Kenya Key, Psy.D. (Chief of Psychology), 1. David Kelner, M.D. (Chief of Psychiatry), and J. Carlos Gomez, Psy.D. (Mental Health Director).
As always, I found the stafffrom CHSCC and CCDOC to be courteous and helpful throughout my five-day site visit.
In this report the term "inmate" will be used in contrast to "detainee" in order to be consistent with the Agreed Order's terminology, although the vast majority of persons admitted to CCDOC are pre-trial detainees.
Overview
The Cook County Department of Corrections consists of 9 main divisions in a group of buildings covering over 100 acres. The inmate count during April20, 2016 was 8,282.
Reference should be made to Appendix I for a more detailed summary of population and capacity information.
Findings
As per the June 3, 2010 memorandum regarding the June 2, 2010 meeting that included attorneys from the Department of Justice, attorneys and representatives of the Defendants, and the monitors, my findings relevant to the Mental Health Care section of the Agreed Order are summarized in Appendix IV (5-13-10 Agreed Order Mental Health provisions). Appendix IV includes excerpts from prior site assessment reports ifthey provide relevant contextual information. Consistent with the June 2, 2010 meeting, I have forwarded my input to the other monitors who have primary responsibility for sections that overlap with various mental health provisions as summarized in the June 3, 2010 memorandum.
Appendix II summarizes the twelve mental health provisions of the Agreed Order that have been in substantial compliance for at least 18 months. My assessment during this site visit did not raise any concems that these provisions were no longer in substantial compliance. Appendix III

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USA v Cook County, et al.
Page 3 of9
summarizes mental health provisions of the Agreed Order monitored by other monitors. Information Requests Appendix V summarizes my revised document request for my next site assessment scheduled for November 14-18,2016. Please do not hesitate to contact me if I can answer any further questions. Sincerely,
Jeffrey L. Metzner, M.D.

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Executiv1e Summary-Twelfth Monitoring Report (Mental Health Provisions)
Since the November 2016 site visit, the most significant progress has occurred in the following six areas:
1. Continued improvement in the mental health programming (both in quantity and quality) for inmates in the RTU and Special Care Unit.
2. Continued improvement in the quality improvement process, which remains in substantial compliance.
3. Continued implementation of out of cell structured therapeutic programming for male RTU segregation inmates.
4. Continued implementation of the Intensive Management Unit (IMU) in the RTU.
CCDOC has recently initiated a plan for increased out of cell time for all inmates in segregation units as part ofthe CCDOC plan to gradually increase the recreational time for segregation inmates to three hours per day. In addition, up to six imnates at a time are allowed to recreate together in the dayroom. This positive change in the milieu related to the increased out of cell time was very apparent. In addition, the custody staffis providing limited correctional programming on a weekly basis to inmates who are willing to participate.
CCDOC has also eliminated administrative segregation, which has contributed to the decreased number of imnates on a segregation status.
There is a total of 118 FTE mental health positions with 18 vacancies that represents a 15.25% vacancy rate. The vacancy rate has continually decreased although the vacancy rate for psychiatrists and psychologists remain problematic.
The leadership ofKenya Key (ChiefPsychologist, Ph.D.), David Kelner, M.D. (ChiefPsychiatrist) and Carlos Gomez, Psy.D., Christopher Wirth M.D. and Connie Mennella, M.D. remains impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is good.
No additional provisions of the Agreed Order are now in substantial compliance for at least 18 months, which means a total of 12 provisions continue to be in compliance for at least 18 months.
One (1) provision previously in partial compliance is now in substantial compliance, which means there are now six provisions that have substantial compliance for less than 18 months.
A total of eight (8) provisions remain in partial compliance.
The main obstacle related to the provisions in partial compliance center on the following issues:
1. the current vacancies re: psychiatrists and psychologists, 2. the need for increased mental health staffing allocations, 3. current lack of adequate mental health programing for female RTU segregation
imnates,

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 2 of8

4. current lack of adequate mental health programming for protective custody RTU inmates,
5. the need for increased recreational time for RTU inmates, and 6. the need for increased out of cell time for inmates in the psychiatric special care units.

CCDOC and Cermak leadership staff are actively addressing the above obstacles.

Summary of Compliance Findings

The following provisions were assessed to be in substantial compliance (with the initial date of substantial compliance noted in parenthesis):

Substantial compliance (bolded provisions have been in substantial compliance >18 months)

59. Assessment and Treatment

a. Results of mental health intake screenings (see proVISIOn 45.c, "Intake Screening") will be reviewed by Qualified Mental Health Stafffor appropriate disposition. (6/12)

b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates' mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs. (10/12)

1.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with a mental health caseload roster listing the inmates

currently receiving mental health care. (6/12)

J. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified! Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status. (10/12)
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
(11115)

2

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 3 of8
L Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. (ll/15)
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year. (6/12)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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. (4/16)
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
3

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 4 of8

b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

c. 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. (11/13)
62. Suicide Precautions

a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.
c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.
d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions ofthe watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards ofcare. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances. (11115)

63.

Cermak shall ensure that Qualified Mental Health Staff assess and interact

with (not just observe) inmates on Suicide Precautions, and document the

assessment and interaction on a daily basis. (11/10)

64. Suicide Risk Assessments

4

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 5 of8

a. Cermak 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.

b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality;
(5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment
shall be documented on both the assessment form and in the inmate's medical record. (11/13)

65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. (11115)
66. Suicide Prevention Policies

a. CCDOC shall ensure that suicide prevention policies established jointly with
Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards. (6/12)

67.

DFM shall ensure that cells designated by CCDOC or Cermak for housing

suicidal inmates shall be retrofitted to render them suicide-resistant (e.g.,

elimination of protrusive shower heads, unshielded lighting or electrical

sockets). Inmates known to be suicidal shall not be housed in cells with

exposed bars. (6/12)

68. Suicide Prevention Training

a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics:
(1) the suicide prevention policy as revised consistent with this Agreed

5

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 10 of 100 PageID #:5009
Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 6 of8
Order; (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 (Serious
suicide attempts are typically considered to be those that either were potentially life-threatening mr that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools. (12/10)
70. Cermak shall document inmate suicide attempts at the Facility, as defmed by the Suicide Prevention Committee's policies and procedure in accordance with generally ac,cepted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this A~Teement. (6/12)
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identifY, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each develop and implement policies to address and correct deficiencies that are uncovered during the course ofquality management activities, including monitoring corrective actions over time to ensure sustained resolution, for each of the provisions of this Agreed Order applicable to that Defendant. (11/15)
The complete list of provisions that were in partial compliance were as follows:
59. Assessment and Treatment
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on
6

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 7 of8

emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staffwith appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-1R, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record.

d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
e. Cermak shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.

f.

Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates' serious

mental health needs and ensure that psychiatrists see inmates in a timely manner.

g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defining the various levels of care and identifYing the space, staffing, and programming that are appropriate to each identified level of care.

h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate.

k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.

I. Cermak shall ensure that mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation ofregular rounds in the segregation units at least once per week by adequately trained Qualified Mental Health Professionals or by Qualified Mental Health Staff with appropriate, on-site

7

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supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours ofplacement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. o. Cermak 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. p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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.
8

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USA v Cook County, et al. Page4 of9
Appendix I

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 14 of 100 PageID #:5013
CDDK CDUNTV SHERIFF•& DFFICE
BUREAU OF INFORMATION AND TECHNOLOGY BUSINESS INTELLIGENCE UNIT
Sheriffs Daily Report 4/20/2016

4/20/2016

Page 1 of 1

DRAFTv1.0

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 15 of 100 PageID #:5014
COOK COUNTY SHERIFF'S OFFICE
BUREAU OF INFORMATION AND TECHNOLOGY EIUSINESEI INTELLIGENCE UNIT

Male

Div 1 Div 2 Div3 3 Annex Cermak Div4 Div 5 Div6 Div08 Div9 Div 10 Div 11 Div 17 W. Residential! Div 15- HP...... VRIC In Camp
...
Outlying Counties

1923
659 104
976 628 960 747 1526
28 20 90

Female
25 240 244 112

Total
0 1923
0 659 129 240 0 976 872 960 747 1526 112 28 20 90

Capacity
1250 1960 360 749 148 552 992 992 979 1066 768 1536 152
I

No Place To Stay
0 34 0 0 3 3 0 1 31 1 6 0 0 2 0 0

4/20/2016

Page lofl

DRAFTv2.0

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 16 of 100 PageID #:5015 Re: Mental Health Services at CCDOC
USA v Cook County, et al. Page 5 of9
Appendix II

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59. Assessment and Treatment

a. Results of mental health intake screenings (see proviSion 45.c, "Intake Screening:") will be reviewed by Qualified Mental Health Staff for appropriate disposition.

Complian1ce Assessment: Substantial compliance (since June 2012).

Factual Findings:

May 2014 Metzner assessment: Little change from November 2013. Still concerned re: likely false positive screening numbers.

November 2014 Cermak Status Update

From intalce referrals by nursing personnel (female intake= RN; male intake= RN or other nursing designees) conducting screening upon all incoming inmates in RCDC, to the secondary mental health assessments, the following referral numbers represent the percentage of referrals to mental health by month from May 2014 through September 2014, which show that the male intake and secondary mental health referrals are remaining essentially constant at this point, while there is a marked increase in female referrals to secondary mental health assessment. Further investigation by the way of a QI study of the Initial Intake Evaluation will need to be conducted.

SECONDARY MENTAL HEALTH REFERRALS GENERATED BY INTAKE NURSING:

Male % Referral

Total Female% Referral

Total

May_2014 23.37%

832 3560 May_2014 57.08%

246 431

Jun 2014 22.41%

762 3401 Jun 2014 64.30%

272 423

Jul_2014 24.82%

865 3485 Jul 2014 63.79%

273 428

Aug_2014 22.48%

918 4083 Aug_2014 65.46%

290 443

Sep_2014 22.17%

774 3491 Sep_2014 79.42%

274 345

The chart below looks at the data from all new admissions to the mental health caseload, by month and gender. The charts reflect those inmates identified and classified as P-2, P-3, or P-4 during the secondary mental health assessment at intake or within the three days following admission versus those who were placed on the mental health caseload at some later point during incarceration. The inter-rater reliability study has not yet been conducted for the Mental Health Specialists within RCDC due to staffmg levels and other competing priorities. The data reflects continual improvements in identifying mentally ill inmates at the onset of incarceration.

MENTAL HEALTH CASELOAD GENERATED BY INTAKE V. DURING

INCARCERATION:

Admit Month Male

Mental Health Classification within 3 day after Admit Mental Health Classification

During Incarceration

9 2014

95.28%

4.72%

8 2014

92.32%

7.68%

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 18 of 100 PageID #:5017

7 2014

90.12%

9.88%

6 2014

89.37%

10.63%

5 2014

87.22%

12.78%

Admit Month Female

Mental Health Classification within 3 day after Admit

During Incarceration

9_2014

93.68%

6.32%

8_2014

88.09%

11.91%

7 2014

83.73%

16.27%

6 2014

87.20%

12.80%

5_2014

81.95%

18.05%

Mental Health Classification

November 2014 Metzner assessment: Substantial compliance remains.

b. Cermak shall develop and implement policies and procedures to assess inmates with mental ill11ess; and to evaluate inmates' mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs.

Assessment: Substantial compliance (since October 2012)

i. Cermak shall provide the designated CCDOC official responsible for inmate disciplinary hearings with a mental health caseload roster listing the inmates currently receiving mental health care.

Assessment: Substantial compliance (since June 2012)

Factual Fiindings:

October 2012 Cermak Status Update

• Cemer is now able to generate a patient roster for the mental health caseload to provide to the CCDOC; however, it does not yet include the level of care/mental health classification as this is being built within the alert system.

November 2013 Metzner assessment: Substantial compliance continues.

November 2014 Cermak Status Updates

Cemer and CCOMS now have a fully operational, direct interface which makes mental health classification/level of care immediately and accurately available to CCDOC by midnight each day.

November 2014 Metzner assessment: No change

j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 19 of 100 PageID #:5018
disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness sb.ould be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status.
Assessment: Substantial compliance continues (since October 2012).
Factual Findings:
Novembe1r 2015 Metzner assessment: Substantial compliance continues
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Fiindings:
June 20ll Metzner assessment: In addition to the above update section, staff demonstrated a capacity to also include dosages of the psychotropic medications in the required log.
October 2012 Cermak Status Update
• The mental health roster has been updated. The roster is being updated routinely. Any inmate on the roster who is identified as missing an ICD 9 code as the result of data entry of a free text or another issue in Cemer is subsequently referred to a psychiatrist for entry of a diagnosis and problem in correspondence to any prescription of a psychotropic medication.
November 2014 Metzner assessment: No change.
61. Suiicide Prevention Policy a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 20 of 100 PageID #:5019
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. 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.
Compliance Assessment: Substantial compliance (11/13)
Factual Findings:
November 2013 Metzner Assessment: Significant improvement is noted in the Mortality & Morbidity Review reports, which are now using a root cause analysis format.
As described elsewhere in this report, problems remain relevant to the intake screening/assessment process, especially in the context of priority referrals and segregation admissions screening. These issues are addressed elsewhere in this report.
Novembe1r 2015 Metzner assessment: My April2015 recommendations were implemented. Substantial compliance continues.
63. Cermak shall ensure that Qualified Mental Health Staff assess and interact with (not just observe) inmates on Suicide Precautions, and document the assessment and interaction on a daily basis.
Compliance Assessment: Substantial compliance (since November 2010)
Factual Fiindings:
November 2013 Metzner Assessment: The EMRs of 10 inmates on suicide observation status were reviewed. Documentation was present in the EMR that mental health staff interacted with (not just observed) these inmates on Suicide Precautions and documented their assessment and interaction on a daily basis with one exception. A patient on 2N while on suicide precautions only received nursing notes one day, 10/20/13, which was a Sunday. There were no mental health assessment notes documented that day.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 21 of 100 PageID #:5020
NovembeJr 2014 Metzner assessment: No change.
64. Suicide Risk Assessments
a. Cermak 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.
b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record. (11/13)
66. Suicide Prevention Policies
a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings:
November 2014 Metzner assessment: No change
67. DF'M shall ensure that cells designated by CCDOC or Cermak for housing suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings:

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 22 of 100 PageID #:5021
October 2:012 Cermak Status Update:
• Inmates known to be suicidal are not housed in cells with exposed bars; rather, they are trarrsported urrder 1:1 observation by a CO to Cermak arrd placed into a suicide resistarrt cell, as ordered by a psychiatrist, when deemed to be a suicide risk, arrd placed on close or constarrt observation, as ordered in Cemer.
Novembe1r 2014 Metzner assessment: No charrge.
68. Suicide Prevention Training
a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established! with CCDOC, addresses the following topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools.
Compliance Assessment: Substarrtial compliarrce (since December 201 0)
Factual Fiindings:
April2013 Metzner assessment: Relevarrt training continues to be provided to staffby the mental health staff.
November 2013 Metzner assessment: No charrge.
May 2014 Cermak Status Update
DOC Advanced Mental Health Training for In-Service: The DOC has now initiated its second of marry s<;heduled two-week in-service training courses for existing DOC tenured Correctional Officers in Advarrced Mental Health Training to include Crisis Intervention Training (CIT) arrd Cermak Health Services participates in the CIT component through a Correctional Psychologist who describes the Cermak mental health delivery system arrd the mental health classification

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 23 of 100 PageID #:5022
procedure as well. This program is provided at the jail on-site in training facilities within the compound although it is from the Academy curriculum.
Cermak Suicide Prevention Training: The Cermak mental health training in Suicide Prevention for mental health, nursing and medical professionals is ongoing and is offered routinely to ensure that all staff maintain their current status in suicide training according to policy requirements. A Correctional Psychologist provides this training at least twice annually to assure ongoing adherence to requirements in training and also offers Restraint Training as well.
November 2014 Cermak Status Updates
Same as above, training continues for all disciplines as described in May 2014 Cermak Status Update.
November 2014 Metzner assessment: No change
70. Cermak shall document inmate suicide attempts at the Facility, as defmed by the Suicide Prevention Committee's policies and procedure in accordance with generally ac1:epted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Fiindings:
October 2012 Cermak Status Update: • All inmate serious suicide attempts are monitored and reported at the Suicide Prevention Committee that occurs on the fourth Friday of each month in Cermak, conducted by the Chief Psychologist, with an agenda and minutes maintained. A detailed report of each serious suicide is completed and reviewed by a Correctional Psychologist at the committee meeting following the attempt and it is treated as a morbidity review for the learning experience. CCDOC incident reports and Cermak medical records as well as court reports are included in the morbidity review. Serious suicide attempts are also reported to the monthly overall CQI committee and to the Sheriffs Office. Any serious suicide attempt also receives an alert in Cemer and in IMACS which is now also passed on to the Courts so that they are aware of any history as well. There had been two instances of serious attempts in court, where the court was not aware of prior attempts. As a result, the Court now participates in the monthly suicide prevention meeting and is now aware ofthese alerts in Cemer and IMACS, a notable improvement directly attributable to a serious suicide attempt.
October 2012 Metzner assessment: Substantial compliance continues.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 24 of 100 PageID #:5023
May 2014 Cermak Status Update:
Suicide Prevention Committee Review: The Suicide Prevention Committee attempts to meet on the fourth Friday each month and the agenda has a standing item to review any and all serious suicide attempts for patterns that could identify areas for improvement to prevent future occurrences from repeating events. Meeting minutes reflect review of individual cases and ongoing efforts to prevent recurrence by efforts to correct any deficiencies identified. DOC, Cermak, the Sheriff's Office and the Court Officials all participate in this multi-disciplinary meeting.
November 2014 Cermak Status Updates
Suicide Prevention Committee Review: The Suicide Prevention Committee attempts to meet on the fourth Friday each month and the agenda has a standing item to review any and all serious suicide attempts for patterns that could identify areas for improvement to prevent future occurrences from repeating events. Meeting minutes reflect review of individual cases and ongoing efforts to prevent recurrence by efforts to correct any deficiencies identified. DOC, Cermak, the Sheriffs Office and the Court Officials all participate in this multi-disciplinary meeting. Full Root Cause Analyses are completed during these meetings for any completed suicides oc:curring in the 30 days prior. Root Cause Analyses are also used for other sentinel events as determi11ed by administration. RCAs for two completed suicides since last site visit provided as password protected files under separate cover.
November 2014 Metzner assessment: Substantial compliance continues

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 25 of 100 PageID #:5024 Re: Mental Health Services at CCDOC
USA v Cook County, et al. Page 6 of9
Appendix III

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 26 of 100 PageID #:5025
Appendix ill
Mental health provisions of the Agreed Order monitored by other monitors
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
Compliance Assessment: Refer to the report by Dr. Shansky (initially found to be in substantial complianc,e during 2011 and again during 2013)
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with re~Ldily available, safely secured, suicide cut-down tools.
Compliance Assessment: Refer to the report by Susan McCampbell.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 27 of 100 PageID #:5026 Re: Mental Health Services at CCDOC
USA v Cook County, et al. Page 7 of9
Appendix IV

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 28 of 100 PageID #:5027

AppendixN The Agreed Order Status Update Page 1 of 57

AGREED ORDER

D. MENTAL HEALTH CARE

59. Assessment and Treatment

c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, fmds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record.

Compliance Assessment:

Partial compliance with paragraph c.

Factual Findings:

April2016 Cermak Status Update

March2016 Total Jail Population as of04/01/2016: 8,096

P2-0utpatient Mental Health P3- Intermediate Mental Health P4- Infirmary Mental Health Mental Health Caseload

1550 19.14% (oftotal) 394 4.8% (oftotal) 65 0.8% (oftotal) 2,009 (24.81%)

77.15% (ofMH load) 19.61% (ofMH load) 3.23% (ofMHload)

Total Jail Population as of 10/01/2015: 8,751

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 29 of 100 PageID #:5028

Appendix IV The Agreed Order Status Update Page 2 of 57

P2-0utpatient Mental Health P3- Intermediate Mental Health P4- Infirmary Mental Health Mental Health Caseload

1571 17.94% (oftotal) 382 4.36% (of total) 69 0.78% (of total) 2022 (23.08%)

77.6% (ofMH load) 18.8% (ofMH load) 3.4% (ofMH load)

As the total jail population has contracted by 742 detainees, the number of patients on Mental Health Case1oad has remained relatively stable. Furthermore, the proportion of detainees in Intermediate Level of Care - P3 has remained constant. Various diversion programs at CCDOC has not diminished the proportion of the seriously mentally ill and the violent offenders, thus the confined population remains as "sick" as it was in 2015.

All Providers, Psychologists, MSW and MHS continue to use their personalized access to the Jail Data Link database allowing them to source data about previous admissions to municipal and state institutions receiving federal grants or directly administered by the State of IL. All Providers, Psychologists, MSW and MHS have personalized access to the Jail Management System (CCOMS) allowing them to review charges, legal and disciplinary history in real time. All the WYSE terminals and desktops that Cermak utilizes across the compound (including RCDC) permit CCOMS access. Mental health staff are routinely seeking releases of information for community providers during the intake process and post intake when needed. Results of the yield in recent month can be found below:

Treatment Records from Community Providers

Oct 2015 to March 2016

REQUEST MONTH SENT

Oct-15

17

Nov-15

49

Dec-15

78

Jan-16

108

Feb-16

212

Mar-16

197

TOTALS

661

RESPONSE RECEIVED*
14 22 37 53 96 73 295

%Return 82% 45% 47% 49% 45% 37% 45%

The number of records requested from community providers has steadily increased from a low of 17 in October 2015 to a high of about 200 in February and March 2016. MH health professionals working in RCDC!Intake are more conscientious about executing ROis with patient. Some of the challenges to executing ROis include: patient refusal, patient is poor historian, patient cannot recall or patient provides wrong/inadequate information.

Medical Records staff indicated that the number ofproviders from which records are being requested increased. Thus, their effort to focus on a few high-volume providers has not had

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Appendix IV The Agreed Order Status Update Page 3 of 57
much impact on the rate of submission of records from community providers.
As of 3118116 every single MHS employee completed the review of all 59 policies, both those that were updated and those that were not.
CCDOC Executive Leadership proposed to introduce additional Mental Health Screening in RCDC (in addition to the pre-bond court screening already conducted by Sheriff's Office for Mental Health Advocacy staff) and the assignment of the CCDOC RCDC MH Referral Alert. CCDOC would like to work with Cermak to identify intake screening questions that would warrant a prompt referral to Cermak and add them to the CCDOC initial intake process. Executive CCDOC Leadership proposed that CCDOC adds the "DOC Mental Health Referral" alert for any detainee:
A. With the charges Cermak previously identified (the idea is to identify the charges that lead to intense guilt, shame and similar feelings that increase the risk of suicide): • Predatory Criminal Sexual Assault • Abuse of a corpse • Sexual relations within families • Dismembering a human body • Conspiracy to commit murder/solicitation to commit murder • Intentional homicide of an unborn child • First degree murder when the following aggravating factors are present: killing of a peace officer, murdering two or more individuals, murdered individual was less than 12 years of age, matricide, patricide, the murder involved infliction of a torture, death resulted from exceptionally brutal or heinous behavior or wanton cruelty).
B. Those with affirmative responses to mental health-related questions asked at the lock up by local law enforcement and
C. Any other agreed upon questions (4 sample questions were introduced for further Cermak feedback):
• Have you ever been prescribed medication for emotional, behavioral or mental health concerns?
• Have you ever been in the hospital for mental health concerns or on "Suicide Watch" in jail or prison?
• Have you ever been in counselingfor an emotional, behavioral or mental health concern?

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• Do you have thoughts or a plan to hurt yourselfor someone else?
Cermak Leadership met with CCDOC Executive Leadership regarding this matter, in order to gauge the potential for mutual collaboration going forward. Furthermore, Cermak was informed that Northwestern Hospital is in the process of working on a grant designed to create a system allowing identification, tracking, and referral of detainees requiring linkage services in the community. This process would be complementary to already existing Cermak supported process of providing post discharge referrals, access to services, and medications via the e-prescribing pathway. (See Appendix for range of services provided by Cermak Medical Social Work staff). Cermak was informed that the computer based system that is being developed by Northwestern would be relying on self-report and answers to a questionnaire. Cermak recognizes the importance of accurate and comprehensive referral and evaluation of detainees with SMI. Cermak is exploring further venues for collaboration while trying to answer pertinent framework questions:
1. Is addition of yet another self-report based screen (see four sample questions above) seem reasonable or do CCDOC and Cermak need to think about augmenting already existing assessments with observational data from RCDC officers (e.g. bizarre and unusual behavior) while focusing on collateral sources of information (reports from CPD and other arresting Police Departments, available EMR, jail data link, other electronic databases)?
2. Is the introduction of a two tier system - CCDOC Primary screening followed by Cermak Primary screening- justified? The recommended positive combined referral rate ranges from 25 to 33 percent. Present Cermak Primary Screening data are available below. Will there be a compounding of the false positive rate (that is "accepting in" the detainees without true mental health needs and SMI) when it is added to the false positive rate that already comes from the Cermak's Primary Screening? A screening system that accepts high false positive rates may lead to inefficient use of resources that is large numbers of detainees without MH needs receiving assessments possibly delaying assessments and treatments for those who with the highest need.
During the screening process, for rare but severe illnesses (i.e. psychosis and suicidal ideation), a two stage screening process may be acceptable. It may be tolerable to have a high false positive rate at the first stage (Primary Screening), followed by secondary level triage (Secondary Mental Health Assessment). Cermak will continue to discuss the CCDOC proposal while focusing on using already existing validated instruments and processes in order to maximize detection of detainees in need of services and assessment through:
a. minimizing the number of false positives (adequate sensitivity) b. keeping the false negative rate low under certain threshold (low false negative rate ).

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The Agreed Order Status Update Page 5 of 57

On averag1e more than 40% of female detainees and approximately 20% of male detainees are referred for secondary mental health assessment from the initial health screening. Please see Excel Appendix for Intake Referral data. Currently, Dr. Gomez is acting as the clinical supervisor in the RCDC area. During RCDC group supervisions case conferences, including peer review, are conducted to address the quality of secondary mental health assessments and identify outliers among staff. The main focus is to discuss quality of dispositions and risk assessments. Dr. Gomez conducted a thorough audit and analysis of assessments and dispositions made by the Intake QMHP staff. This RCDC QI report can be found in the PDF Appendix.

Dr. Kelner reviewed psychiatry referrals originating in the intake process as per below (also see Excel Appendix for data):

Psychiatry Intake Referrals:

Emergency Seen within 4hrs Not Seen

Month

#

2) Over4hrs %

# %

2015 10 38

97.4%

0.0%

2015 11

159

99.4%

0.0%

2015 12

179

93.7% 4

2.1%

2016 1

155

82.9% 14 7.5%

2016 2

169

90.4% 12 6.4%

4) No Note in Intake # % # %

Total

1 2.6% 1 2.6% 39

1 0.6% 1 0.6% 160

8 4.2% 12 6.3% 191

18 9.6% 32 17.1% 187

6 3.2% 18 9.6% 187

In February 2016 90.4% detainees were seen within 4 hours (in keeping with the timeframe) when referred with Psychiatry Emergent Referral. Out of the 9.6% that were not seen timely, 6.4% were still seen in RCDC (Intake) but outside of the 4 hour timeframe. 3.2% were not seen in Intake, as they were either fast tracked, given acuity, prior to Psychiatrists being able to see them, to PSCU and MSCU/detoxification units. Additionally, a small proportion of that cohort had orders for Psychiatry Intake placed in EMR when it was assumed by MHS that Psychiatry would be present on site, but then, due to call offs Psychiatrists did not show up and original orders were not cancelled.

Urgent(F'4)
2 2016 I 2016 12 2015 11 2015

1) Within 24 hrs

97

91.%

76

93.%

69

84.%

79

88.%

2) Over 24 hrs

8

7.%

5

6.%

1l

13.%

10

11.%

No Note

2

2.%

I

1.%

2

2.%

I

1.%

Total
107 82 82 90

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Appendix IV The Agreed Order Status Update Page 6 of 57

l1o 2o15

71

92.%

3

4.%

3

4.%

77

In February 2016 91% of detainees referred for Urgent Psychiatry Referral were seen within 24 hours (in keeping with the tinieframe). The 7% of detainees that were not seen within the next 24 hours were mostly detainees admitted on Fridays and weekend Psychiatrists saw fuem later in fue day and detainees who were assigned P4 level (were "slated" for PSCU admission) and fuen were diverted to MSCU and detoxification Units, thus delaying fueir contact wifu Psychiatry. Nursing and Medical staff in MSCU is still responsible for fue identification of P4's and sending these notifications to fue Chief of Psychiatry. Since fuere is no the Scheduling Template, fuese detainees are frequently missed. See discussion below about fue relevance offue new Infirmary Tracker enabling Psychiatry to track fuese detainees in MSCU/Cermak building and see them timely. Th<e Tracker is anticipated to go live in April of2016 and would enable Psychiatry to timely locate P4 detainees on fue 3 rd. floor/MSCU.

Routine(P2/P3)
2 2016 1 2016 12 2015 11 2015 10 2015

1) Within 14 davs
315 58%
323 65.% 365 65.% 326 55.% 406 60.%

2) Over 14 days/within
30davs 50 9.%
22 4.%
23 4.%
28 5.%
26 4.%

3)D/C within 15
davs 135 25.%
120 24.%
139 25.% 183 31.%
190 28.%

4)D/C over 15
days without
Note 13 2.%
14 3.%
15 3.%
36 6.%
40 6.%

5) No Note 28 5.% 18 4.% 19 3.% 17 3.% 15 2.%

Total
541 497 561 590 677

In February 2016 58% detainees referred for Routine Psychiatry referral were seen within 14 days (in keeping wifu fue timeframe). 25% were released from CCDOC within fue same timeperiod before Psychiatry had a chance to see fuem. 9% were seen by Psychiatry outside offue tinieframe (but within 30 days). The last number reflects high vacancy rate in Psychiatry and fue fact that many divisional clinics already functioning at fueir capacity. 2% were released within a month and wifuout being seen by Psychiatry and 5% were eifuer shipped to outside counties or to IDOC. Of note is fuat that Cemer continues to capture IDOC shipments (most offuem were parole holds upon admission to CCDOC) as being physically on campus and, therefore, they are seen as "never having contacts wifu Psychiatry". Dr. Kelner is addressing this glitch with IT. Additionally, detainees' rate of transfer between divisions/ clinical areas remains significant, as CCDOC transfers patients between divisions VI, II and X for fue purposes of bed control/ disciplinarY reasons, therefore clinic appointments get missed and , when rescheduled for later time, detainees fall out of fue requisite timeframes. CCDOC and Cermak leadership meet regularly to discuss bed control and to identity ways of making fue system more efficient.

The following has been introduced to facilitate tiniely contacts wifu Providers in Cermak. Mental Health Caseload detainees (P2, P3 and P4) patients that were admitted to MSCU (Medical

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Special Care Units) from RCDC/UC w/out a clinic template presented a challenge in terms of tracking. We need a process that supports their timely identification and facilitates their being seen by Psychiatry in keeping with the time frames (Urgent- within 24 hours and Routine within 14 days). We had to rely on Medical Providers and Nurses identifying these patients and reporting them directly to a single point person - Chief of Psychiatry.
Daily PSCU Mental Health Level of Care Tracker was created by IT and Mental Health. It will enable to track the following metrics:
1. P-level detainees throughout the whole building will appear on the tracker (including staging and MSCU's).
2. Will inform Providers about whether or not Psychiatrist had contact (i.e., wrote a note ) with a detainee and if they did, when the contact occurred.
3. Needed follow up for close observation status patients will be indicated. 4. Tracker will prompt Provider to write a note by a specific date to remain in policy
compliance (that logic will be built in the tracker).
The creation of the tracker enables mental health to remain aware of patient status throughout the building and addresses the fact that there are no schedulers working on the weekends and that there are no psychiatry clinic templates to schedule detainees on the 3rd floor (MSCU). A sample ofthe Tracker can be found in the PDF Appendix.
Some chal!lenges have been created by inappropriate requests for Psychiatry Referrals from MHS and PCC Providers for detainees already established on MH caseload, rather than the appropriate follow up with Psychiatry. MH Administration also insists that every detainee who is referred to MH Department for services and evaluation, excluding crisis management, receives a structured Secondary Mental Health Assessment (with the embedded Suicide Risk Screen/Suicide Risk Assessment) prior to ordering Referral to Psychiatry. Additional efforts have been put into educating Mental Health Specialists and PCC providers on the distinction between Referrals to Psychiatry and Follow up to Psychiatry. Mental Health Specialists performing these Secondary MH Assessments will make appropriate referrals to Psychiatry.
Chart audits has revealed an intrinsic problem in RCDC/UC revealing that many MHS allowed the default to the following day when ordering Routine Psychiatric Referrals and not selecting a remote dat,e. MH Administration will continue to work with the Unit Directors and drill down to select appropriately a date within 14 days when MHS schedule Routine Psychiatry referrals. The clerks/AAs responsible for the schedule do not always adhere to the 14 day tirneframe for a variety of reasons, some known (i.e. clinic template full) and others unknown (i.e. instances where there are available appointments within the required time frame). Additionally, when detainees have to be rescheduled in divisions (i.e. due to No Shows for a variety of reasons), the rescheduled dates are sometimes outside of routine time frames. Education was provided to scheduling department as a group and individually. (Please see the Excel Appendix for data

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Appendix IV The Agreed Order Status Update Page 8 of 57
reflecting Routine Psychiatry Referrals).
With respect to JSH, EM and outlying county returns, further improvements have been made in tracking detainees returning on CCDOC campus. There is a new daily report generated automatically for hospital returns (15HP). This report is being sent to CHSC 1128A printer in MH Administration area. It lists all the hospital returns over the past 24 hours. The list includes P/M levels: and medications pre-transfer. The ones that had not dropped off are listed as "ordered" and the ones that need to be reordered are listed as "discontinued". (A sample of this report can be found in the PDF Appendix.) MH Administration worked with CCDOC Leadership to formalize the way outlying county returns are processed back onto the compound.
Based on the schedule provided by CCDOC, MH administration created a new, standing OT shift to allow Mental Health Specialists to be available to assess returning detainees. Furthermore, Chief of Psychiatry is notified of outlying county returns so that medications can be reordered. Of continued concern is that SPIDOC shipments and outlying county stays continue to show up as "unseen" when the logic used to capture data even though they were not on campus at the time of their scheduled psychiatry appointment. Resolutions for this problem, which adversely affects compliance data is being explored by IT.
Urgent Care Center has introduced a new tracking system (FirstNet) allowing a more efficient control of the flow of detainees in UC. Now PCC Providers and Nurses can move detainees needing a MH assessment to the MH tab, therefore decreasing if not eliminating reliance on verbal hand offs and endorsements that can easily be missed or misinterpreted in a fast paced environment. Additionally, formally incorporating mental health into the flow of the urgent care will serve to minimize miscommunication, minimize missed assessments, and minimize inappropriate discharge from the urgent prior to completion of all needed services.
The stop order medication reports are now generated for Divisions and are designed to identify pt's whose prescriptions are expiring before their regularly scheduled appointments.
The new alert "MH Fit on Medications" is available under "Chronic Disease Alert" order. This alert DOES NOT go into CCOMS/CCDOC System. It will be utilized for detainees who return from DMH restored to fitness on medications or found to be FST on this compound with medications. It will be entered by RCDC Psychiatrists, or whoever conducts the first Evaluation upon their arrival without end dates applied.
The new alert "Authorized Involuntary Medication" is available in Cemer and migrates through the CCOMS interface. It will be utilized for detainees who have court orders for Involuntary Medications (non-emergency basis). Even though court orders have an expiration date, for tactical reasons, Cermak will use this alert without time restrictions. It will be entered by a Provider who serves as a Petitioner and goes to court to argne the petition, in case the ruling authorizes the Involuntary Treatments.

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April2016 Metzner assessment: Significant progress has been made in the following areas as summarized in the April2016 Cermak Status Update section:
1. Timely assessments by psychiatrists re: urgent and emergent referrals. 2. Requesting and obtaining mental health records from other agencies.
Issues relevant to psychiatrist's timely responses to routine referrals are directly related to the continued significant psychiatrists' vacancy rate.
I discussed issues relevant to the proposal by Northwestern Hospital with staff and made certain nonbinding recommendations since it is not within the scope of the Agreed Order.
Recommendations: Continue addressing the psychiatrists' vacancy issues.
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Partial compliance
Factual Findings:
April 201C) Cermak Status Update
COMPOUND HOUSING PLAN BY MENTAL HEALTH LEVELS OF CARE (as of April 2016)
Cermak- P4 (Psychiatric Special Care Unit)- 2N acute male, 2W-acute and chronic female, 2S/2SE- male subacute, 2E- male chronic, P4 can also be housed on the third floor in Medical Special Care Unit under special circumstances. Housing on 3S for Mental Health reasons requires Tx orders from PCC/ Dr. Mennella. Patients with M4 and P4 can be housed on the Medical Special Care unit based in interdisciplinary decision.
• Division II: MALE MENTAL HEALTH HOUSING • Dorm 2: Mental Health Outpatient P2; **if any Mental Health Intermediates (P3) are placed there, Dr. Gary works transferring them to RTU; CCDOC houses detainees that attend MHTC (Mental Health Transition Center) in Division II Dorm 2 • Dorm 1: NO MENTAL HEALTH HOUSING • Dorm 3: NO MENTAL HEALTH HOUSING • Dorm 4: NO MENTAL HEALTH HOUSING
• Division IV FEMALE MENTAL HEALTH HOUSING DD(Wom~n's Justice- SWJP): FEMALE MENTAL HEALTH HOUSING- 1" Floor

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AppendixN The Agreed Order Status Update Page 10 of 57
• Mental Health Intermediates P3 (requires clearance from DWJS staff) • Mental Health Outpatients P2 (requires clearance from DWJS staff) D OMental Health Outpatient P2- 2nd floor • Division V: NO l\1ENTAL HEALTH HOUSING • Division VI: MALE l\1ENTAL HEALTH HOUSING o Westcare tiers- 2A/2B/2C (substance abuse, court ordered treatment program), Mental Health Outpatient P2 o Protective Custody: IA, IB and IC • Mental Health Outpatient P2 (only require mental health clearance prior to
placement/ within 24 h if restricted housing rules apply) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division VI; they should only be cleared for PC in Division VIII RTU o Segregation: Tiers IN, IP • Mental Health Outpatient P2 (require mental health clearance prior to placement/within 24 h) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to segregation in Division VI; they should only be cleared for segregation in Division VIII RTU • Division VIII RTU: l\1ENTAL HEALTH HOUSING o 5th floor Females • Mental Health Intermediates P3 (tiers B, F) Mental Health Outpatients P2 and DETOX (all other tiers) • Segregation (tier A) Protective Custody (tier E) (restrictive housing require mental health clearance prior to placement/within 24 h) o 4th floor Males • Mental Health Intermediates P3 (all tiers) • Segregation (tier A) Protective Custody (tier E)
• Mental Health Intermediates P3 (restrictive housing require mental health clearance prior to placement/within 24 h)
o 3'd floor Males • Medical Intermediate M3s (may also be P2s) with overflow Mental Health Intermediate P3 s
o 2nd floor Males • Mental Health Intermediate Overflow P3 (tier 2B) • Intensive Management Unit (tier 2A)
• Division IX: MALE l\1ENTAL HEALTH HOUSING o Protective Custody (Tiers 3E, 3F, 3G house alone/out alone/ admin. segregation, 3HPC) • If conditions of confinement are more restrictive than GP, Mental Health Outpatient P2 require mental health clearance prior to placement/within 24h **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division IX; they should only be cleared for segregation in Division VIII RTU

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o Segregation- non-administrative segregation (Tier IE; IF- enhanced security tier) • Mental Health Outpatient P2 (require mental health clearance prior to placement/within 24h) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to segregation in Division IX; they should only be cleared for segregation in Division VIII- RTU
o General Population (all other tiers in the division) • Mental Health Outpatient P2
• Division X: MALE MENTAL HEALTH HOUSING: Mental Health Outpatient P2 **if any Mental Health Intermediates (P3) are placed there, Dr. Gary works on transferring them toRTU o Disciplinary Segregation- !A (require mental health clearance prior to placement/within 24 h or preplacement) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to segregation in Division X; they should only be cleared for segregation in Division VIII RTU o Protective Custody -1 C (meeting criteria of smart housing) and 2C • **No Mental Health Intermediates should be cleared by mental health to transfer to segregation/PC in Division X; they should only be cleared for segregation in Division VIII RTU
• Division XI: NO MENTAL HEALTH HOUSING • Division XVl (Boot Camp): NO MENTAL HEALTH HOUSING; detainees on dose by
dose medications carmot be in Boot Camp (and that excludes any patient on psychotropics)
Compound Housing Discussions:
There has been no further development on the Division XI project and plans to relocate P2 detainees from Divisions II, VI, and IX and X have been tabled indefinitely.
The plarmed transition to MHTC (Mental Health Transition Center) residential setting has not taken place yet. CCHHS seeded 3 million dollars for additional hiring to staff the transition center program. However, Cermak and CCDOC Executive Leadership staffs have not had discussions with each other regarding the timeline for onboarding of additional staff to accommodate medication management in the residential MHTC.
The Health & Hospital System is partnering with the Cook County Justice Advisory Council and the Chicago Police Department to open a pilot Community Triage Center this year. The community-based center will seek to provide evaluation, crisis stabilization and treatment for patients presenting with psychiatric and/or substance-related emergencies, and will work closely with the local hospitals and outpatient mental health services to best meet patients' needs 24/7/365. Access will be prioritized for police officers to drop off individuals and rapidly return to their patrol areas. The CTC will also provide walk-in services for those released from the Cook County Jail. (See PDF Appendix).

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Appendix IV The Agreed Order Status Update Page 12 of 57

RTU Staf1[mg Levels.

Psychiatrist Psychologist/Unit Director Social workers Mental Health Specialists

RTU 5th floor females
1.2 1.0 1.5+ 1.0 Expressive therapist 2MHS III +4MHS II on AM 2MHS III + 2MHSII on PM

RTU 4th floor(+ 2nd and 3rd floors) 1.4+0.2 ( PA)=l.6 1.0 1.5+1.0 Expressive therapist 4MHS III+ 4MHS II on AM 4MHS III+ 1MHS II on PM

Population

P3 76 P2 132 ( 208)

1MHS III+ 1 MHS II on Midnight Shift ( for the whole RTU)
P3 256 P2 4 ( 260)+ additional 101 P2 and 40 P3 on the 2"d and 3rd floors

RTU total population 608 P2 237 P3 371 Detainees with medical alerts/detox on the second and! third floors -141

Division IV Proposed movement to Division 4, which was intended to merge Division III and Division XVII (SWJP), took place in January 2016. It consolidated female P2 detainees and enabled Cermak to consolidate services centripetally. Detainees from SWJP remain spatially isolated (on the first floor of Division IV) from other detainees housed on the 2nd floor of the building. Psychiatric Services, Mental Health Services, and community meetings were not interrupted due to coordination of services between CCDOC and Cermak and a series of meetings and walk through sessions that had taken place before the actual move. Psychiatry FTE 03. P2-140, P313.

FemaleRTU Psychiatric Services in RTU- 5th floor have been unchanged. Cermak continues to provide limited stmctured out of cell therapeutic programming to detainees on the protective custody tier (5E), group programming is not yet available to patients confined on the segregation tier (5A) as the tier has not been retrofitted to allow detainees to be secured to stationary furniture. CCDOC has expressed concerns that said retrofitting is not gender-responsive; as such safety mechanisms will need to be put in place in order to allow for safe facilitation of group therapeutic programming with this challenging population. Cermak will continue to provide segregation rounds and individual therapeutic contacts for segregated patients and/or aggressive patients.

Executive Summary ofWomeu's Mental Health Services

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AppendixN The Agreed Order Status Update Page 13 of 57
The team has increased efforts to facilitate individualized group treatment by staffing each P3 patient regularly and using the treatment cards (also to motivate patients). Patients are involved in the treatment planning process and create a problem list with the tier mental health specialist who is familiar with her. All (100%) ofP3 treatment plans are initiated and updated on time. The quality of treatment plans drastically improved. Outpatient (P2) treatment plans are created by psychiatrist and have drastically increased in compliance for new P2 patients. P3 patients do receive 10 hours of group on a regular basis. P2 average 2-4 hours of group per month. Protective Custody patients receive 2 hours of group per week. Female Services has a very low self-harm rate. Self-injuries that do occur are usually a few specific patients when housed in segregation. CCDOC escorts all detainees to a mental health provider for assessment prior to placement in segregation and all are escorted for subsequent Cermak mental health assessments if indicators of self-harm are noted by the CCDOC staff.
SMU Rounds are completed twice per week (both in PC although not required and Segregation). Patients ar,e assessed by MH within 24 hours of placement in segregation. PC tiers receive 2 hours of group per week. A significant number of P3 and P2 patients receive individual therapy services in RTU and in Div. 4 for more personalized treatment. There has been improved consultation with CCDOC with respect to identifying what constitutes referral for an urgent psych evaluation, which are completed in a timely manner. RTU provides 24 hour on-site evaluations and consultation. Unit Director periodically attends roll call to discuss psych evaluations and referrals. We continue to focus expressive arts and linkage services on P3 patients. P2's receive linkage services on a selected or referred basis.
We have seen improvement with patients who have poor hygiene. Rise and shine occurs 5 days per week and hygiene supplies and encouragement are provided. Patient's displaying ongoing, serious hygiene concerns (generally psychotic) are discussed in MDT clinical staffmg and are admitted to the psychiatric special care unit for increased support and a humanitarian shower. Patients who have marginal hygiene are being encouraged and offered an edible treat or Dove body wash for hygiene compliance. Beauty shop services have increased in RTU and in Div. 4.
Psychiatrists are meeting with patients within 1-3 days if deemed a priority. Routine appointments for new patients are occurring within 14 days. P3 patients are receiving monthly appointments (significant improvement since the last site visit). We are also receiving more records from community providers via ROI for continuity of care.
Div. 3 (Cermak) and Div. 17 (SWJP) have combined to form Div. 4. The results are quite positive. The patients generally prefer the Div. 4 housing better than Div. 3. Cermak and SWJP treatment staff are working well together and have increased communication, providing improved treatment for all Div. 4 patients. Communication between mental health and CCDOC has greatly improved. Enrichment programs have been implemented for P2 and GP patients (Book Club, Theater Group, Anger Management, Yoga, Legal Aid, and sewing workshop). New strategies have been utilized among mental health, nursing, and CCDOC staff to cut down on the number of female patients being moved by CCDOC between RTU and Div. 4. There are very

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Appendix IV The Agreed Order Status Update Page 14 of 57
few moves that are occurring, improving compliance with appointments and decreasing patient stress.
Female services has been working with a shortage of two (licensed) mental health specialists, which poses clinical challenges. Less experienced mental health stafftoo frequently rely upon showing v[deos for group, which has resulted in some patient complaints. Such issues have been addressed in individual and group supervision. Facilitating interactive groups has increasingly been discussed in group supervision. While some staff members have shown improvements, others have shown little to no improvement. As a result, there was a change in staff duties in hopes of decreasing patient concerns.
Mental health facilitates a movie discussion group for treatment compliant patients every two weeks. Incentive items (t-shirts, bras, panties) are randomly given to those attending the most groups, takings meds, and following CCDOC rules. We are also providing a standardized letter of participation monthly for patients attending 75% of reco=ended treatment groups. Few women are receiving the letter of participation due to lack of consistent attendance, which frankly was a surprise as we expected tangible "proof' of compliance with treatment to take to court would be a considerable motivator. Long-term patients (particularly SF) struggle with the eventual redundancy of the treatment videos and materials often reporting that they are bored.
Patients have also reported becoming bored on the tiers and a desire for increased recreation. In order to increase collaboration in consistency of clinical programming, CCDOC is kept up-todate with the mental health group schedule to avoid having the recreation schedule conflict with group times. Mental health looks forward to assisting with creative group activities for recreation time (i.e. bowling tournaments, etc.).
Ongoing issues related to patients trying to acquire as much medication as possible, hoarding and abusing the medications is addressed in group and individual treatment. Mental health continues to work with nursing and security to identifY and monitor patients engaging in these behaviors. Once patients are identified as engaging in these behaviors, a "Hoards Medication" alert is entered into the medical record. This alert migrates to CCOMS so that all parties are aware and increased monitoring of the patient can take place.
There has been a sharp increase in patients submitting HSR forms making demands for specific medications, often submitting multiple, daily for the same issues. Usually documenting "anxiety" and "I can't sleep", so "I need X medication." Some patients directly inform the mental health staff that they intend to submit the requests daily until they are given what they are requesting. To address this issue co=unity groups, HSR contacts, and psych evaluations are including sleep hygiene, anxiety management, and relaxation/ coping skills, however little impact has been noted.
Mental health staff has expressed concerns related to delays in patient movement and monitoring of clinical activities. Mental health hopes to work toward maintaining consistent officers on

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Appendix IV The Agreed Order Status Update Page 15 of 57
mental health tiers who are advance psych trained and work better with mental health patients. A list of recommendations has been provided to the Superintendent for consideration. The RTU 5th floor periodically experiences issues with housing changes for patients which can be disruptive to programming and patient stability. Recently the Superintendent and Commander have been addressing the issue and indicate that all moves should be done only through classification, hopefully preventing future issues.
Please see PDF Appendix (Monthly Statistics 2016) for group programming statistics.
MaleRTU
Psychiatric Services in RTU- 4th floor have been bolstered by the addition of the Part -time Physician Assistant. The relatively small increase in PTE's allocated to the 4th floor reflects ongoing staffmg challenges. Due to the preplanned movement ofWestcare detainees from Division II Dorm 2 to Division VI, Cermak had to respond to the centrifugal force and fragmentation of services provided on the compound, by assigning PTE 0.1 to Division VI while offsetting that by moving FTE0.1 from Division II Dorm 2 to male RTU, thus, keeping the staffmg levels in the high priority area (RTU) constant.
Executive Summary of Male RTU Services
RTU Male Services has continued to implement several changes since November of2015 to individualize mental health services and to enhance the treatment milieus on 6 dorms, 2 specialized units on the fourth floor (segregation and protective custody), the Intensive Management Unit (IMU), and the P3 overflow dorm on the second floor. The programming on these tiers is described below as well as the strengths and the challenges of each area. Based upon feedback from detainees and previous DOJ reports, efforts have been made to provide more individualized treatment services for P3 detainees on the fourth floor. In the past, detainees attended group based on bed number. Logistically, this system facilitated scheduling and tracking of groups, but did not necessarily provide detainees with significant input regarding their treatment plan. In August of2015, several staff members held "voluntary" groups to assess patient interest in signing up for more specialized groups. This format reportedly enhanced motivation and participation in groups per staff and detainees, so was subsequently expanded to the entire £ourth floor. In November of2015, detainees signed up for voluntary groups based upon their interests and perceived treatment needs. Mental health staff also assigned individuals to specific groups given their chart review, clinical presentation, and observed behaviors. In December of2015, Verification Letters were also introduced as incentives for individuals who attended at least 75% of their groups. Detainee attendance is monitored on individual treatment cards.
Overall, the Verification Letters and voluntary groups seem to have enhanced the motivation and treatment experience for many detainees. Each dorm typically earns between ten to thirteen letters each month (25-30%). Several challenges have emerged with this new system. In

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particular, the MH team has had difficulty tracking group enrollment and maintaining a system to orient new detainees. Currently, mental health staff conducts orientation groups to inform new detainees about the structure ofRTU program and treatment expectations. At that point, detainees sign up for groups and have initial treatment plans developed. Due to staffmg and/or institutional issues, orientation groups may need to be rescheduled, which then delays the onset of group enrollment. Further, some detainees request to sign up for numerous groups while others remain reluctant to participate altogether. This discrepancy potentially limits the opportuni~y detainees have to enroll in groups and to earn verification letters. These factors along with staff absences, both planned and unplanned, often interfere with the consistency and efficiency oftreatment prograrnrning. Staff assignments have been changed to increase the number of mental health specialists conducting orientation groups, developing treatment plans, and monitoring group enrollment. The treatment team will continue to make adjustments to streamline these processes.
In August of2015, treatment groups were initiated on the segregation tier ofRTU (4A). At that time, groups were co-facilitated on three mornings ofthe week with three detainees at a time. After a trial period without significant problem or incidents, group prograrnrning was expanded to five of days of the week (Monday through Friday), during both morning and evening shifts. Up to six detainees can now participate in on tier sessions. In addition to group prograrnrning,
MH staff conducts segregation rounds once per week as well as individual tollow up with
detainees. Our goal is to provide ten hours of programming per week; however, MH staff has struggled to consistently increase and maintain treatment hours for several reasons. When the program was developed, the mental health team and CCDOC agreed two officers would be necessary to hold and supervise the group. Due to institutional needs, two officers have not always been available for the group, which occasionally interfered with total hours provided. To avoid repeated disruptions in prograrnrning, the safety plan was eventually adjusted to include at least two officers present for the transport of detainees and one officer present for the group. With respect to other obstacles, groups are sometimes difficult to hold on the unit when detainees are engaging in highly disruptive behaviors (throwing urine and feces, making threats, etc.). Moreover, MH staff has had difficulty engaging detainees who refuse to participate in groups. Some detainees are highly symptomatic and prefer to isolate in their cells while others are resistant to have group in a setting where other detainees can hear personal discussions. Although the segregation unit on the fourth floor previously housed only P3 detainees, recent institutional changes resulted in this tier serving as the only segregation unit in RTU. As a result, the tier is now mixed with intermediate care, outpatient care, and general population detainees. This environment is not always conducive to on tier programming and seems to contribute to group refusals on occasion. After consultation with security, MH staff was granted permission to hold off tier groups when necessary. MH staff attempt to do so whenever room space is available. The treatment team will continue to consult with CCDOC about incentives for group participation in segregation. The following have been discussed as potential alternatives to food incentives: supervised time on the patio as well as participation in on tier activities such as bowling, music, and art. Although decreased segregation time has been proposed, this option has been more controversial.

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Detainees housed in protective custody are not permitted to attend off tier groups with other P3 detainees. Consequently, on tier group programming was originally scheduled for this tier (movie discussion, chair yoga, arid emotional management). These sessions were ultimately discontinued due to low participation. Staffresources were refocused to other dorms, with individual follow up and crisis intervention as the main mental health services provided to protective custody detainees. Recently, some of the newer detainees have expressed interest in participating in the aforementioned groups, which have now resumed.
A P3 overflow donn was opened on the second floor ofRTU to reduce the number ofP3 patients displaced to other areas of the compound. This dorm was intended to provide temporary housing for detainees awaiting space on the fourth floor. Since its creation, the P3 overflow dorm has varied in overall size and population. To illustrate, the dorm houses P3, P2, as well as general population medical patients. At times, the dorm has been dominated by P3 detainees; at other times, the dorm is mostly medical patients. For several weeks, 2B was closed altogether due to low population. Detainees were initially expected to move up to the fourth floor within two to three weeks. Consequently, the mental health services provided to P3 detainees on this donn included wellbeing checks twice a week. Periodic community meetings were added in February of 2016 due to the increased number of P3 detainees housed on 2B at that time as well as the increased length of stay for those individuals. Mental health services were again increased following 1he completed suicide of a P3 detainee on this dorm. Currently, stati is scheduled to provide wellbeing checks twice a week, community meetings once a week, and on tier groups two days a week.
Presently, detainees in need of hygienic procedures (excluding, thus far, haircutting) are to be admitted in a preplanned way to the psychiatric special care unit where Cermak MH leadership and the Superintendent have developed the hygiene protocol allowing for the coordinated administration of hygienic services. When warranted, detainees displaying disorganization of behavior (along with the other salient criteria) are considered and petitioned for the nonemerge:ncy administration of psychotropic medications.
Intensive Management Unit (IMU) The Intensive Management Unit (IMU) is on the second floor or RTU. This specialized program is designed to provide increased structure and support for mentally ill detainees who have demonstrated significant problems in their functioning. The program consists of three successive phases (Assessment and Admission Phase-minimum 2 weeks; Stage 1- minimum 4 weeks; and Stage 2-minimum 4 weeks) which offer increased incentives as the detainee progresses. All of the detainees selected for the program thus far incurred notable segregation time due to severe behavioral problems (e.g. assault against others; property damage; sexual misconduct; threats and noncompliance). These detainees were informed their participation and successful completion of the program could result in absolution of segregation time for previous disciplinary tickets. The first three detainees moved into the IMU unit in October of2015., MH and CCDOC staff were selected and trained to participate in the IMU unit. To date, the program has housed a maximum of four detainees, two of whom have successfully graduated

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and have r'eturned to a dorm setting without behavioral incidents to date. One detainee has progressed. to Stage 2 and is eligible to graduate at the end of April, 2016. The last detainee has remained in the Assessment and Admission Phase since October due to his repeated noncompliance with treatment and behavioral expectations. The IMU team meets for weekly staffings and holds on tier meetings with the detainees every other week to review treatment progress and expectations. The collaboration and communication amongst this disciplinary team has been essential to facilitate the progress of detainees.
Currently, the team continues to work on maintaining consistency across shifts and personnel, as lapses in mles and regulations have periodically jeopardized the integrity of the program. The recent departure of one Commander and addition of two new Commanders to the building highlighted the need for a clear and thorough description of the program. A joint manual for both MH and CCDOC staff is being developed to address the issues and questions that have arisen over the past six months. Another training session will then be scheduled for new and existing staff to discuss strengths, weaknesses, and recommended adjustments to the program. For example, the team is considering the IMU for mentally ill detainees who would benefit from celled housing, but have not accrued segregation time.
Since the last DOJ visit, RTU MH staff has focused on individualizing treatment services and expanding the groups offered to male detainees. In addition, staff has increased individual follow up for detainees who demonstrate poor hygiene and significant symptoms of mental illness. Regarding challenges, MH staff absences continue to impact programming, as does problems with supervision of CCDOC staffing allocations. Further, limited space and computers make it difficult to conduct all clinical activities and charting on days when all staff is present. Requests have been made to activate the computers on the second floor to allow access to Cemer <md for mental health staff to be able to utilize computers in the medical triage rooms on the tier, particularly as MH presence increases on 2A and 2B.
Please see PDF Appendix (Monthly Statistics 2016) for group programming statistics.
Division II Dorm 2/P2
Houses 0, Rand P housing Westcare patients have been moved to Division VI. MHTC detainees are housed in the V house. Overflow P3 are still housed in Division II Dorm 2 until a bed opens in RTU and Cermak staff transfers them immediately using bed control tools. Within the past few months there has been a concerted effort to conduct community groups in all ten tiers on a weekly basis. At times, these groups have not occurred due to security issues, employee absence, and employee vacation. There is a MHS III assigned during the evening (3-11) shift on Tuesday, Wednesday, and Thursday. Telepsychiatry Clinic continues to provide reliable coverage fior this Division and remains the strongest assignment in terms of productivity and meeting expectations. The initiative is meeting expectations. Dr. Marri's clinic, due to growing demand in RTU, has been limited to mornings on Tuesday. The mental health staff is working well with security. Supt. Martinez has been very open to the needs of mental health. As

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mentioned elsewhere, Dr. Kaniuk functions as a Unit Director for Divisions X and II. FTE for Psychiatry is 1.1. Population: P2-392.
Division 2 Dorm 2 Executive Summary Division Two -Donn Two houses P-2 and M2 (outpatient level of care) patients. Recently, the population changed somewhat by the influx of many more "medium" security detainees from Division Ten, after the Westcare substance abuse program was transferred to Division Six. These individuals can be more problematic at times. Thus, this means more referrals to mental health through HSRF, mental health clinic, or emergency evaluations.
Staff absenteeism has been a significant problem in this area. There are two employees assigned during the 7-3PM shift but due to vacation and sick time, they are often absent. Also, the MHS III (on both shifts) is occasionally reassigned to the Cermak building or Division Ten due to operational need. Thus, community groups are significantly impacted. At this point, there is one MHS III assigned during the 3-llPM shift on Tuesdays, Wednesdays, and Thursdays. Employees are rotated periodically from Division Two to Division Ten (and vice versa) in order to avoid burnout.
Mental health staff works well with security. They refer individuals who request an evaluation or have a question, as well as those who display behavior problems. This is done formally (Inter-Agency Health Inquiry) and informally. The mental health staffs, along with the CRW's, meet with Supt. Martinez on a weekly basis.
The telepsychiatry clinic is working very well. There are only minor problems with the computer equipment (on site and with Dr. Ward). The detainees receive these services with very few complaints. She sees approximately 14 (10 in the morning, 4 in the afternoon) patients on a daily basis, with a combination of new evaluations and followups. Dr. Marri is only in Division Two- Dorm Two for one-half day per week, which makes telepsychiatry even more critical. Dr. Marri must see detainees who need translation services.
The nursing staff processes HSRF forms before giving them to mental health staff. On occasion, there is a delay in processing the forms. The detainees who write these requests are seen by the mental health staff in a timely manner. In general, the mental health staff works well with the nursing staff.
There is a medical social worker assigned full-time to work in the building. He addresses family issues, discharge medications, and provides linkage services to community agencies.
Division VI/P2 Executive Summary Westcare patients formally housed in 2D2 were moved to Division VI, which significantly changed the culture and demand for the full range of health services in a division primarily accustomed to housing majority general population detainees. Division VI continues to have a segregated population on the tiers IN and lP, as well as a recent addition of a third segregation

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tier, 1Q. Psychiatry FTE was increased to 0.2 to acco=odate the increased population (P2174). Additionally, in response to the population change, a second mental health specialist (QMHP) was assigned to the division resulting in 7 day coverage on the 3p-11p shift. Mental health staff conducts segregation rounds, responds to HSRF, and facilitates mental health clinic 6 days each week. A schedule is currently being developed to begin co=unity meetings on six designated tiers which house the majority of the P2 patients. The Chief Psychologist is currently acting as the Unit Director for the division due to psychology staffing vacancies. The weekly psychology clinic for the division is facilitated by one of the Cermak Unit Directors. Cermak and CCDOC divisional leadership meet weekly to discuss divisional concerns. CCDOC divisional leadership has been very responsive to requests and feedback from Cermak supervisors, a very good working relationship is being established. With the significant culture change, which is accompanied by novel issues for the current staff, continued dialogue will need to occur with respect to urgency of action related to mental health and health needs. The Chief Psychologist and Nurse Manager will continue to provide feedback as needed around these issues at the divisional meetings. A medical social worker is assigned to the division to address linkage needs and discharge medications for selected or identified patients.
Division IXIP2 Executive Summary
In the fall of 2015 more than one hundred detainees with P2 alerts from non SMU tiers were transferred to Division 10. It led to less fragmentation of Psychiatric Services and transfer of 1 FTE MHSIII from Div. IX to Div. X). The remaining detainees with P2 alerts are either on the Enhanced :Security tier, Segregating tiers, and Protective Custody tiers. Very few of them are remaining on non SMU tiers. The Level System ofAdministrative Segregation has been dismantled. Special Incarceration Unit has been closed. Remaining Segregation tier is 1E. Tier IF is converted into "Enhanced Security Parameters" tier. Detainees identified as institutional threat and engaging in actions designed to disrupt operations are concentrated on the above tier with enhanced movement and security precautions. It was clarified by CCDOC Leadership that the qualifying behaviors must not be rooted in or related to mental illness. Those with serious staff assaults, serious inmate assaults and those that repetitively disrupt CCDOC operations are considered. Placement is at the discretion of the executive leadership. In the beginning all security/custodial functions were carried out by ERT (Emergency Response Team) but, eventually CCDOC was trained in these duties and presently manages this tier. See full CCDOC Memorandum stipulating pertinent objectives and means in the PDF Appendix.
The following are Patient Safety and Enhanced Security Guidelines for patients who present with self-harm (Foreign Body-ingestion, insertion and pill ingestion) in Division 9 & 10 designed to complement the enhanced security parameters and reduce the amount of disruption of operations: CCDOC staff presents patient to the Divisional Dispensary for triage and evaluation by the Nurse, as is the current process. A referral to the Urgent Care is made, if advised by the Nurse. Nursiog indicates on the transfer envelope the type of self-harm (i.e. pill iogestion, foreign body ingestion, etc.) the patient has presented with. Nursing notifies the CCDOC transporting officer who notifies Admissions at extension 5802 to notifY them anticipated transfer of inmate to

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Urgent Care. Nursing determines the appropriate timeframe for transfer and will notifY DOC of timeframe. (Please see PDF Appendix)
The following is a guideline for transfer: Pill Ingestion: transfer to Urgent Care within 60 minutes. Foreign Body Ingestion/Insertion: transfer to Urgent Care within 4 hours. If there is an inmate in Division 9 who states that he's ingested "pills or medication" and there is a wait time to be seen in the Urgent Care, he will then be taken to Division 10 (if nurse available) for initial triage and taken back to Division 9 (if stable) to wait for transfer to Urgent Care. Suggested Guidelines: for Management of Patients after Foreign Body Ingestion have been developed as a result of a collaborative effort between CCDOC, Department of External Operations, Cermak Administration, John Stroger Hospital Risk Management Department, JSH Emergency Room staff, and JSH Gil Internal Medicine Department. These guidelines operationalize transfers, observation, alimentation, and treatment of patients engaging in frequent self-injurious behavior, for non-suicidal reasons. All the above measures have been developed in response to the formation :and rise of a jail gang named "Savage Life". This organization openly professes their mission as designed to disrupt operations and inflict chaos through acts of self-injury and noncompliance with orders/rules. Cermak Mental Health started limited structured out of cell therapeutic programming on 1F utilizing the services of two staff Psychologists. 1F has been retrofitted to allow detainees to be secured to stationary furniture during group therapy. Protective Custody tiers remain on 3E, F, G, H. Cermak staff is working with corrections to understand the role differentiation of Cermak Mental Health providers and Sheriffs Mental Health staff. Ongoing role clarification will assist in smooth coordination of patient care when differing cllinical opinions exist between the two agencies. Fallowing the resignation of Dr. Rogers, Dr. Key had to assume the role of the Unit Director. Psychiatry FIE 0.2. P2-61. Mental health staff conducts segregation rounds, responds to HSRF, and facilitates mental health clinic 6 days each week.
Division ~JP2 In the winter of2016 1-D was closed as a segregation unit and presently serves as non SMU housing tier (as of October 30th, 2015 1D was disciplinary segregation). 1A remains a disciplinary housing tier. Retrofitting 1A furniture to allow securing detainees to stationary furniture during out of cell structured therapeutic programming ( planned at this time) was identified as priority during the last Interagency Compound wide planning monthly meeting and Department of Facilities Management is going to start the project. Elsewhere in the division, on non SMU tiers, Cermak continues provide co=unity meetings supplemented by CRW programming provided by CCDOC staff. Below is a snapshot of the co=unity group activity for the month of March 2016:
Community Groups conducted = 15 Community Group Cancellations = 30
Detainee behavior = 11 Mental health staff absence = 8

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Security reassignment for other duties = 5 Emergencies in the building = 2 Mental health staffneeded to conduct emergency evaluations = 2 Milieu issues (power washing tier)= 1 Milieu issues (nurse passing meds) = 1
Division X received a large number of non SMU detainees from Division 9 as a onetime transfer in the fall of 2015. Following the implementation of the new PC criteria by CCDOC, Division X now houses two PC tiers- 1C (clean, where more stringent criteria are applied for entry) and 2C (where criteria are not as stringent). Dr. Kaniuk (Unit Director) still manages Division II Dorm 2 and Division X (both housing P2) and his workload is substantial due in part to the distance between those two divisions and overall patient population. Overflow P3 (minimal most of the time) are still housed in Division X when necessary until a bed opens in RTU and Cermak staff transfers them immediately using established bed control tools. Telepsychiatry Clinic's opening and preparation took many months to implement. Cermak Administration had assisted in identifying and training Administrative Assistants who were to function as Clinic's Attendants. Dr. Kelner created a tutorial for JSH Providers. Dr. Kulik committed two JSH Providers to staff the clinic on a part time basis. The Clinic was eventually opened in February 2016 and remained operational until March 2016. Then one of the JSH Providers resigned from CCHHS and the other Provider was replaced by a Locums Physician. The clinic can be reopened, when operational demands arise. FIE for Psychiatry is 0.9. MH population: P2-530. Utilization of Division X as P3 overflow has decreased with the opening ofRTU 2B as a P3 overflow tier in September 2015.
Div. X Encutive Summary
Division Ten houses M2, P2, and some General Population (GP) detainees. There have recently been an inJlux of detainees from Division Nine, replacing the medium-classified individuals who were transferred to Division Two- Dorm Two. This has created an even more challenging patient population. There are SMU tiers for Disciplinary Segregation and Protective Custody. There were initially two disciplinary segregation tiers (1-A and 1-D) but now only one (1-A). The cell windows have been covered over with thick plastic within 1-A, in order to stop the detainees from throwing containers of bodily fluids or feces on staff members. The tier has an average census of about 40 detainees. The demands for mental health evaluations in this tier are quite significant. Also, many of these evaluations are for suicide risk assessment. There is a special tier for detainees who are exposing themselves to staff (3-D).
The mental health staff work well with security staff, who is very receptive to our concerns. The mental health staff, along with nursing staff and CRW staff meet with Supt. Walsh on a weekly basis. There have been some difficulties, specifically on the 3-11 shift, with presentation of multiple detainees to be evaluated who may not be in need of an emergency assessment which presents challenges for staff with respect to completing routine duties (clinics, HSR, rounds, etc.).

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Psychiatry has two providers assigned most of the week. Telepsychiatry was instituted for a brief time but discontinued. There is a problem on Thursdays for psychiatry due to PC's being seen in the dispensary. Unless the psychiatry schedule contains PC detainees that day, the psychiatrists often are delayed for about one hour or so.
There are four mental health workers assigned to the 7-3 shift. Absenteeism is somewhat of a problem. Also, MRS III's are reassigned to Cermak or RCDC whenever there is a clinical need. Thus, the shortage of staff is pronounced from Friday through Monday. The detainees in Division Ten are very challenging in regard to programming. There are three group therapies (community meeting with a psycho-educational component) scheduled on Tuesdays, Wednesdays, and Thursdays. There is an assigned security officer, who escorts the mental health worker on to the various tiers. The television is turned off which upsets many detainees. Other detainees are taking showers or some just voice their displeasure at a mental health worker on the tier, disrupting their daily routine. In a few instances, detainees are exposing themselves in front of female mental health workers. Thus, it is not easy conducting groups in Division Ten.
It is not always easy to see detainees who write HSRF. This is due to the logistics of the building (i.e. getting people out of cells, conunissary day, emergencies where all available are needed in a certain location) and lack of MRS III, due to reassignment. As a result, many evaluations are done cell front or on the tier with as much privacy as possible.
Employees are rotated periodically from Division Ten to Division Two (and vice versa) in order to avoid burnout.
CCDOC Submitted Updates
Compound Housing: DOC, Cermak and Facilities collaborated on the closures of3 divisions since the last site visit. On 1131116 inmates from Divisions 3 and 17 were transferred to Division 4, which had been temporarily closed and undergoing renovations for the past two years. The Division 3 population comprised all security classifications -minimum, medium and maximum. The Division 17 population, home to the Sheriffs Women's Justice Program, traditionally housed minimum security females, with a strong emphasis on vocational programming, drug treatment and mental health counseling. Females taking part in the Women's Justice Program maintained access to the same programming in Division 4.
While Division 17 typically operated at full capacity (approximately 140 women), Division 3 had been running at about 56% capacity (about 195 inmates with available bed capacity of346). Redistributing the female population from two aging buildings into the refurbished Division 4 will save significantly in jail operational costs moving forward.
On 2/8116, DOC, Cermak and Facilities initiated the closure of maximum security Division 1, with those inmates being redistributed to other divisions throughout the jail. The closure was completed on 2/13/16. Division 1 had only been functioning at 44% capacity (about 550 inmates

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with available bed capacity of 1248), so the redistribution will result in a significantly more costeffective utilization of Cook County Jail's buildings. Division 1's correctional staff were assigned to new divisions across the compound, allowing for increasingly efficient staffmg structures and reduced overtime costs.
Mental H1~aUh Transition Center: The Sheriff's Office Mental Health Transition Center (MHTC) doubled its participant caseload in January 2016. The program now averages 100 participants. It remains a day treatment program at this time.
Correctional Programming in Disciplinary Segregation: Effective January 2016, the DOC discontinued the use of administrative segregation. All segregation units are now considered disciplinary segregation. Additionally, in January 2016 the DOC identified inmates that had been causing the most disruption to the compound and moved them to one tier in Division 9 (Tier IF). Many of these inmates were affiliated with the newly formed 'Savage Life' gang. The DOC staffed the unit with staff from the Emergency Response Team. Expectations, unit rules and consequences of rule-breaking behavior were articulated in writing to each detainee. In March 2016, the e:nhanced segregation concept was expanded to include Division 10 Tier lA. In February and March 2016, the DOC was able to reduce the number of detainees in disciplinary segregation, reducing the general population segregation units (those in Divisions 6, 9 and 10) from 8 to 5 living units.
In an effort to minimize role issues between the Sheriff's Office and Cermak mental health staffs, the Sheriff's Office mental health staff ended their provision of group programming on the segregation tiers January 2016. DOC non-mental health program staff now provide correctional programming in the segregation units in Divisions 9 and 10 at least once each week.
Inmate Hygiene: Inmates housed in Division 08 RTU continue to have access to sanitation kits, which are maintained on the living unit. The living unit showers in RTU continue to be power washed on a regular schedule to manage the soap scum.
Recreation: Detainees in Division 08 RTU have access to patio recreation. The mental health units typically go to recreation on the patio at least once weekly. Recreation was minimal in the month of February due to the weather conditions.
Recreation is offered to Cermak 2"d floor detainees on Thursdays, Fridays and Saturdays. Female detainees in Cermak are allowed to go to indoor and outdoor recreation in Division 4, but they often refus·e. Male detainees in Cermak are allowed to go to indoor and outdoor recreation in Division 10.
April20Hi Metzner assessment: Male and female P3 RTU inmates continue to be offered at least ten hours per week of structured therapeutic activities. Female RTU inmates were offered access to the patio during March 2016 on a once per week basis for one hour each week. They will soon have limited access to the Division 4 recreational yard.

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During the morning of Aprill9, 2016 I interviewed inmates in a community meeting-like setting within two RTU female units (SB & SF) and two male RTU units (4B 7 4G). The female inmates were with many more complaints regarding the RTU that focused on issues of limited access to group treatments and the quality of some of the groups. However, many of the complaints voiced by them were not substantiated after obtaining information from other sources (e.g., staff and medical records). The male inmates were much more appreciative regarding the quality of the groups offered. Inmates confirmed that they were being offered at least 10 hours per week of structured therapeutic activities. Discharge planning services were available. In general, medication continuity issues were not present. Limited access to the psychiatrist was present although most inmates reported seeing a psychiatrist on a monthly basis.
Male and female inmates indicated that during the past several weeks they had begun to have access to the patio and nearby recreational yards. Their access had been very limited during the winter months due to the cold weather.
Female inmates who had previously been treated on 2W reported their experiences were very unfavorable. The male inmates generally voiced more favorable reports regarding their experience.s on 2N, 2E, 2S or 2SE.
Appendix VI is a summary of review of randomly selected mental health caseload inmates' medical records that focused on progress notes written from November 2015-April 2016. This review was performed by my fellow in forensic psychiatry under my supervision. Findings included the following:
Fr•:quency of Psychiatry Visits: With few exceptions, patients were seen within the recommended timefrarne (maximum of every four weeks while in RTU and maximum of every three months as P2s). Some notes did not indicate a recommended time to return to clinic so this metric was difficult to track. However, psychiatric follow-up for inmates transferred from the PSCU to the RTU was not timely.
Consistency/Continuity of Plan of Care: The plan and assessment aspect of documentation was variable. Some clinicians were specillc in their targets of intervention and indications for medication changes while other notes made no or limited mention of rationale for therapies. With one patient, it appeared that hospital notes (upon return) were not reviewed or at least incorporated into the plan of care, at least not within a timely manner. Several patients had a myriad of providers throughout their course, but this usually appeared to be a function of location (i.e., moved between units or different levels of care) rather than a function of provider availability.
Diagnosis: Diagnoses largely remained unchanged from visit to visit and were carried over when seen by a new provider. The diagnoses remained consistent. When a patient was seen by a new provider, it often was unclear whether the new

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provider had reviewed the chart and/or done a new, independent assessment of the patient in order to arrive at their diagnosis and plan.
RTU male segregation inmates (4A) are currently being offered about eight hours per weeks of out of cell structured therapeutic activities. RTU male segregation inmates are not all classified as mental health P3 inmates-some are P2 and some are M3. However, P3 inmates are given priority in the context of being offered out of cell structured therapeutic activities. P3 inmates are housed in 4A for up to 10 days per rule infraction ticket.
Female segregation RTU inmates are not being provided out of cell structured therapeutic activities related to CCDOC concern re: the use restraints from a gender sensitive perspective. After discussion with Dr. Jones, Dr. Kelner and Dr. Keys, it was decided that female RTU segregation inmates will be provided out of cell structured therapeutic activities without restraints but with the presence of two correctional officers during the structured therapeutic activities. These officers will receive enhanced mental health training
Protective custody RTU inmates are only receiving two hours per week of out of cell structured therapeutk activities due to mental health staffing issues.
IMU inmates in 2A are offered eighteen hours per week of out cell of structured therapeutic activities. These inmates also receive additional out of cell recreational dayroom time. I interviewed one IMU inmate during the morning of April 19, 2016, who described his experiences on this unit in a very favorable terms. Another IMU inmate indicated a similar experience during a 'group" therapy session that I observed. Two inmates have "graduated" from the IMU and are now residing in a RTU living unit.
Significant improvement is noted relevant to providing out of cell structured therapeutic activities £or IMU inmates and male RTU inmates in the segregation unit.
The decision by CCDOC to discontinue the use of administrative segregation is very encouraging as is the plan to increase the out of cell time in all segregation units and allow up to six inmates to recreate together. There were 217 inmates in disciplinary segregation in the various segregation units throughout CCDOC during April IS, 2016. Data provided by CCDOC included the following:
As recommended, we took a random date of March 15 and determined how long those who were in these seg units on that date had served disciplinary seg time. Please note that there were two people on 4a who stayed for over 48 days, one: of whom was an M3, not a P-3, who had multiple write ups, and the other was a P-3 who had two write ups for a total of36 days, but his time in seg was miscalculated and he spent an extra 12 days in seg. This was addressed with our staff in a meeting on 3117116, where we made the expectation of 14 days or less for P3 inmates in segregation clear for our staff. That inmate was removed from

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segregation on that day. This situation will not be repeated because our Disciplinary Unit will not issue more than 14 days for P-3's. However, it should be noted that Cermak did not mitigate his 26 day and I 0 day seg orders.
RTU 4a : 14.6 avg days, but if you take out outliers, 9.2 days (mixture of all classes) RTU Sa: 9.2 days (mixture of all classes) Div.6 lP: 7.125 days (Min's and Med's) Div.6 IN: 9.04 days (Min's and Med's) Div.lO lA: 7 days (Max) Div. 91E: 16.5 days (Max) Div.91F: 17.04 days (Max)
Recommendations: Implement the plan for structured out of cell therapeutic activities for female RTU segregation inmates. Access to the patio and recreational yards should be significantly increased. It was my understanding that plans are being considered to winterize the patio area, which will provide for more access during the winter months to outdoor recreation.
RTU inmates continue to be offered at least 10 hours per week of structured therapeutic activities. The quality of some of these groups could be improved ifnew psychoeducational videos could be obtained in order to supplement the current videos being used which have been viewed by many of the inmates in the past. The mental health services should have an annual budget for therapeutic programming materials.
Mental health staffing vacancies and allocation issues are directly related to inadequate mental health programming for protective custody RTU inmates
e. Cermak shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
Compliance Assessment: Partial compliance
Factual Fiindings:
April2011) Cermak Status Update
Please see Appendix for Treatment Plan QI Audits for each level of care.
Additionally, multiple comprehensive interagency behavioral management plans have been developed by the Chief Psychologist, the Chief Psychiatrist, Unit Directors in concert with the full multidisciplinary team, when needed for more complex or difficult cases. The majority of interagency plans continue to be generated in PSCU, followed by the RTU.

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April2016 Metzner assessment: QI studies relevant to treatment plans for the various levels of mental health care were reviewed. The treatment plans for inmates receiving a P2 mental health level of ca:re, which are completed by the psychiatrists, have demonstrated significant improvement during the past 12 months. The audit oftreatment plans for inmates receiving a P4 level of caxe included the following summary:
The database of special care patients was reviewed by the PSCU Unit Drrector for compliance with the treatment plan policy. Thirty patient charts were selected at random representing patients housed in various units within Cermak (acute care, chronic care, medical). 93% of charts reviewed had P4 ordered within 72 hours of admission to PSCU. Of the 30 treatment plans reviewed, 28 reflected multidisciplinary representation at MDT, 30 included psychiatry in all P4 and P3 pla:a development, 29 of the treatment plans were completed by a QMHP, and in 23 'cases it was documented that the patient was informed of the plan. PSCU plans will continue to be completed by a QMHP a:ad involving the patient (either by being present during plan development or by informing the patient ofthe plan) will be increased. Treatment plan updates are a:a area for improvement. 13% ofP4 Acute plans were updated within 7 days. 6% of P4 Chronic plans were updated within 90 days. QMHP will improve the consistency with which treatment plans are developed/reviewed/updated. P4 patients will be classified as high, medium, or low with regards to acuity and treatment plans will be reviewed/updated according to the corresponding level of care (every 7 days for high, every 30 days for medium, every 90 days for low). Staff will be trained on these expectations and supervisors will regularly monitor compliance.
The audit of treatment plans for inmates receiving an RTU level of care included the following summary:
The database of all intermediate treatment pla:as was reviewed for compliance with the treatment plan policy. All 90 (1 00%) intermediate mental health treatment plans were completed within 30 days of admission and all updated plans were completed on time. Intermediate mental health treatment plans have maintained compliance for an extended period. All treatment plans were completed by a QlVlliP, in conjunction with the multidisciplinary tea:m a:ad the patient's input. Intermediate treatment plans will continue to be completed by one QMHP who will utilize the excel database for completed treatment plans and due dates to ensure ongoing compliance with due dates. All intermediate mental health patients are reviewed in the MDT staffings and specific problem items with corresponding treatment groups are indicated for each patient on a:a ongoing basis. The quality of intermediate mental health treatment plans has improved consistently by indiividualizing each treatment plan and treatment groups to each patient's needs, with input from the patients. Each intermediate mental health patient receives a "Treatment Card" indicating recommended treatment groups and attendance based

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Appendix IV The Agreed Order Status Update Page 29 of 57

on patient specific needs. Incentives are provided to encourage participation in treatment, such as movie incentives and undergarments. Patients who attend 75% of recommended treatment groups receive a treatment attendance letter for court (8% on average receive a letter).

Recommendations were made relevant to revising the policies and procedures regarding the frequency of treatment plan reviews based on an inmate's acuity level and level of care. The revisions will be sent to me for review prior to being submitted to the pertinent policy committee within Cermak for consideration.

The current process for developing treatment plans for RTU inmates (i.e., one licensed mental health specialist is assigned to write all initial comprehensive treatment plans for female inmates and two lieensed mental health specialists are assigned to write all initial comprehensive treatment plans for male inmates) has been developed due to the licensed mental health specialists'' allocation issues. This process includes involvement with the mental health specialists assigned to the particular RTU unit. There was agreement that this process is better than not having treatment plans but will be changed once the mental health specialists' allocation issues (i.e.,, allocating more licensed mental health specialists positions) are resolved.

I observed a treatment team meeting on 2W during the afternoon of April19, 2016. Due to a leak in the ceiling, which was located where the computer drop-down cable came through the ceiling,
the staff did not have access to the medical record via a computer. Unfortunately, this issue was identified during previous site visits and despite pending work orders it has not been resolved.

Recommendations: Change this process once the licensed mental health specialist positions have been increased so that the assigned mental health specialists develops a treatment plan in conjunction with the inmate and the multidisciplinary treatment team.

It is not acceptable that treatment plans are being developed during treatment team meetings
without access to the electronic medical record. This issue needs to be resolved innnediately by either fixing the leak, providing computer access via another drop-down cable or meeting in a different conference room.

f.

Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates'

serious mental health needs and ensure that psychiatrists see inmates in a

timely manner.

Compliance Assessment: Partial compliance

Factual Findings:

April2016 Cermak Status Update

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Divisional

110

Chief of

Psychiatry

FT Psychiatrist 110

PT Psychiatrist 133

PT Psychiatrist 155

Consultant

Chief

110

Psychologist

Psychologist 110

Physician

110

Assistant

Social Worker 110

Director of

110

Mental He:a1th

Art Therapist 110

MHSlli

110

MHSII

110

MHS Senior 110

Administrative 110

Assistant

Locums

Psychiatrist

Mental Health

Vacant

Filled

Sum

0

I

I

8

7

15

0

5

5

1

1

2

0

I

1

5

5

10

1

I

2

1*

6

7

0

1

1

0

3

3

2

52

54

0

3

3

0

13

13

0

I

I

I

18

100

118

%Vacant 0%
53% 0% 50%
0%
50% 50%
14% 0%
0% 3.7% 0% 0% 0%
15%

The main task remains attracting full time Correctional Psychiatrists through assertive national search and advertisement campaigns. There are presently two Providers in credentialing (Drs. Bednarz and Haq). Please see PDF Appendix.

2 FTE for Psychiatric PA. Current vacancy rate for this group is 50%. It is noted that the starting salary for this group pays less than what constitutes industry average in this market.

Compensation for the PA position seems to remain the main factor hindering recruitment at this point. There are 5 part-time Psychiatrists and in that group all the vacancies have been filled. The majority of part-time (Account 133) Psychiatrists are committed to working between 8 (Lassen) to under 20 hours (Dr. Kartan and Ramie). One part-time position of Consulting Physician (Account 155) remains vacant. Dr. Binius started as a Consulting Physician in March 2016. The rate of compensation for that position is made sufficiently attractive. RCDC coverage remains rather fragmented and services of full-time attendings are sought (on a voluntary basis) to provide evening coverage at the moonlighting rates.

In June 2015 Cermak Mental Health submitted paperwork necessary for the creation of the new non-union position of the Associate Chairman/Divisional Chair for Psychiatric Special Care to

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assist the Chief of Psychiatry in clinical and administrative duties. As of April 2016 the creation ofthis position has not been cleared.
One Locums Tenens Psychiatrist joined the Department in February 2016.She provides PTE 0.3/ week in Dilvision X Clinic.
Our experience with Telepsychiatry in various clinical locations on this campus demonstrated that Mental Health Department needs a position of a Clinic Attendant for diverting Mental Health Sp<:cialists (even unlicensed ones) to the duties of the Clinic Attendant, given their other tasks in RCDC and Divisions, is not sustainable. Dr. Gomez created a functional description of that position in 2015 and further effort will be put in promoting the creation of this job to sponsors at the CCHHS level. An example of productivity and exceeding expectations can be found in the Division 2 Clinic. Division X Telepsychiatry Clinic was opened in February 2016 but, subsequently, had to be closed in March 2016 due to the resignation one of the JSH Providers. Physical layout in Division X does not allow for the intermittent presence of a clinic attendant, as officer in that area supervises, at the same time, a busy HCR clinic and the Psychiatry Clinic, consequently, constant presence of an attendant is necessary to ensure safety. An Administrative Assistant/ Ward Clerk from Division X was assigned to watch the clinic, but it was eventually realized that a Cermak staff overseeing the clinic must be present in that location as long as the Clinic remains open and Administrative Assistants have other duties to perform and could not be dedicated to the Clinic 100%. RCDC Telepsychiatry Clinic remains open and serves an important function, even though there had been some concerns about Telepsychiatry in the acute/triage setting.
Cermak has contracts with 3 (three) staffing agencies to provide Locum Tenens Psychiatrists: Medical Doctor Associates (MDA), Maxim Physicians Resources and Columbus Organization. Cermak is at various stages in the onboarding process for candidates from each of these agencies. Dr. Garb, furnished by Columbus, is the only psychiatrist who has completed the credentialing and HR "purple form" process and is deployed (PTE 0.3) at Cermak. The contracts for the three locum tenens agencies will end in 11130/2016. Based on present clinical needs and recruitment yield, Cermak Mental Health Department projects that we will continue to need staffing assistance. To help address the critical need for psychiatry coverage, Cermak proposes the following two-pronged strategy:
1. Seeking an extension of the contracts for 1-2 years. Recently, all the contracts have been synchronized. So far, the funds seeded in the fmancing of the Maxim, MDA, and Columbus contracts have not been exhausted. The extension would not result in any net costs to the system.
2. Have all three staffing agencies recruit psychiatrists with subsequent buy out by CCHHS. Columbus has a clause that allows Cermak to hire one of their employees. Ml)A and Maxim do not have similar clauses. Amending their contracts may need to be pursued by Purchasing Department at CCHHS.

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One potential caveat is to allow Vendor's recruitment which would have to be reconciled with the Shakman Monitor first. Cermak Mental Health Leadership has submitted these proposals to Cermak Leadership.
Ongoing current recruitment efforts by CCHHS are detailed in the PDF Appendix. The hiring of Providers at Cermak is currently under modified purview ofShakman Monitors. In October 2015 CCHHS informed Cermak leadership that the County will be piloting a new process for recruitment and hiring of Advanced Clinical Providers. The project has been utilized since November 2015. This is the first step in the decoupling of Psychiatric hiring from the Monitors. The Advanced Clinical Position (ACP) Hiring Process resulted in less paperwork, more opportunities for individualized treatment ofcandidates, and fewer delays. Psychiatry, Psychology and PA Positions at Cermak are eligible.
Vacancy Rates, PTE's and Net changes in vacant positions for Psychiatry is available in the PDF Appendix.
There is a total of 10.0 PTE psychologist positions (excluding the Chief Psychologist position) with a current vacancy rate of 50% (5 FTE). One Correctional Psychologist resigned. Cermak has lost several candidates in later stages of their hiring process due to the fact that their internships were not APA approved. Efforts are made to vet candidates early on to identify candidates whose internships would disqualify them from receiving clinical privileges at Cermak.
There is a total of70 MHS Specialist Positions with a current vacancy rate of2.8% (2FTE for MHS III). Currently we 16 unlicensed staff (3 recently achieved licensure and are awaiting reclassification), 52 licensed staff (1 had an administrative hearing and adjudicated). Cermak is currently working with Labor Relations Department to upgrade the staff who recently achieved their licensure in their respective disciplines. All the unlicensed MHS were informed that they needed to get the credentials/education necessary to move to MHS III positions as the MHSII!Senior positions were to be eliminated. Local 73 filed the EEOC complaint with the federal government and the unfair labor complaints with the IL Labor Board. The EEOC complaints were determined to be unfounded and eventually the unfair labor issue ended in arbitration. In January 2016 the issue was decided in favor of the County. The 16 affected staff were to supply County Labor Relations Department with the information regarding their current academic standing, whether emolled full time or part time, where they were emolled, anticipated graduation date from the Master's program and anticipated licensure date. Three (3) of these completed all requirements to transition to Mental Health Specialist III positions as they've earned their Master's degree and are licensed as an LPC, LCPC, LSW or LCSW. Cermak plans to give notice to six (6) of them that their position is being eliminated in accordance with the arbiter's decision. Cermak's goal is to post positions to replace the 6 individuals whose positions are to be eliminated so that we can hire already licensed staff to replace them. There are those who are presently emolled in a Master's program and expected to be eventually licensed. They will be expected to complete their degree/licensure by specific, individualized dates (based on

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current status and anticipated licensure date). If these employees do not achieve licensure by their specified dates, their position will be eliminated.
There is a total of 7 Medical Social Workers Positions; the 7rn position was recently filled with an anticipated start date in May. Positions of tbe Chief of Psychiatry, Chief Psychologist and Mental Health Director are filled.
Staffmg Plan for FE 2017 has been developed by Cermak Mental Health Leadership and can be found in the Excel Appendix.
April2016 Metzner assessment: My November 2015 report included the following:
During July 2014 there were a total of9.70 functional FTE psychiatrists working at CCDOC as compared to the 11.7 FTE psychiatrists during April2015. There were 2.0 PA's employed at Cermak during April2015. There is now a total of 16.0 FTE psychiatrist positions (including the chief psychiatrist position) and 2.0 FTE psychiatric physician assistant positions with 10.4 FTE psychiatrists and 1.0 FTE PA currently employed at Cermak. The current vacancy rate is 49% for psychiatrists/physician assistant positions. There are now 1.3 FTE more psychiatrist/physician assistant vacancies as compared to 2015. However, there are the equivalent of 4.0 FTE locum tenens psychiatrists who are currently in the credentialing process. The locum tenens contract was rec,ently modified to include telepsychiatry, which significantly increase the applicant pool. In addition, two psychiatrists working at Stroger Hospital will be providing a morning per week ofTelepsychiatrist clinic time in the near future.
There is a total of 11.0 FTE psychologist positions (including the chief psychologist position) with a current vacancy rate of37% as compared to 45% vacancy rate during April2015. In other words, there is an additionall.O FTE psychologist employed at Cermak as compared to the last site visit.
The recently approved salary increase and the Shakman pilot hiring project sununarized in the current status section are very positive signs and should significantly assist in recruiting psychiatrists.
During the April 2015 site visit, I reported the following:
There is a total of 118 FTE mental health positions with 25 FTE vacancies that represents a 21% vacancy rate
As of the November I, 2015 site visit there was total of20 vacancies, which represents a 16.94% vacancy rate.

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During April2016 there were 11.2 FTE psychiatrists' positions filled (which represented a loss of 0.5 FTE psychiatrists as compared to the last site visit) and 5.0 FTE psychologist positions filled (which represented a loss of 1.0 FTE psychologist position). The total mental health staff vacancy rate has decreased somewhat to 15% since the last site assessment. 2.0 FTE psychiatrists have been hired with start dates of May 1 and July 1, 2016 and 1.0 FTE psychologist has been hired, who will be starting May 1, 2016.
There still appears to be issues with the hiring process, including the credentialing process. Refer to the report by Dr. Porsa for more detailed information.
I discussed with the administrative staff the importance of resolving the issue with the loss ofthe 0.5 FTE telepsychiatrist and issues relevant to arranging for independent forensic psychiatric examinations in the context of nonemergency involuntary medication petitions.
The psychologists' salaries were reported to be equivalent with those available in the community, which was problematic because they did not provide an incentive for working in a correctional environment. In other words, to really be competitive, the salary needs to exceed the average salary available in a public community setting.
Recommendations: As per Dr. Porsa's report. Take steps to make the psychologist' salaries more attractive for hiring and retention purposes.
I also strongly support the creation of the proposed Associate Chair of Psychiatry, Director of Infirmary Psychiatry position.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures def"ming the various levels of care and identifying the space, staffing, and programming that are appropriate to each identified level of care.
Compliance Assessment: Partial compliance
Factual Findings:
Apri12016 Cermak Status Update
Please see Update in 59f. Also see Excel Appendix.
April2016 Metzner assessment: A staffing proposal is in the process of being submitted that will include a request for additional mental health staff with an emphasis on additional licensed

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mental health specialist positions. Although it is clear that additional psychiatry and psychology staff are needed the emphasis will be on the mental health specialist positions due to the issues involved with the current psychologists' and psychiatrist' vacancies. The need for more license mental health specialists is particularly acute within the RTU as evidenced in the sections relevant to treatment plans and services being provided to RTU inmates who have a protective custody status.
The proble:ms associated with the significant vacancies relevant to psychiatrists and psychologiists impact inmates access to care and quality of care issues. It is clear that there has been a direct correlation with a significant decrease in the total mental health staff vacancy rate and significant improvement in the quality of care offered to inmates.
Recommendations: I agree that the emphasis should be placed on the mental health specialist positions £or the reason summarized above.
h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate.
Compliance Assessment: Partial compliance
Factual Findings:
Cermak Male Acute, Subacute and Chronic Mental Health Unit Descriptions
The Cermak male psychiatric units are comprised of 60 beds distributed among 3 units - 2North (acute unit), 2South (subacute unit) and 2East (chronic unit). The purpose of the units is to provide extended observation, stabilization and structured/unstructured therapeutic activities. Services are provided by a multidisciplinary team, which includes psychology, psychiatry, mental health specialists, nursing, social workers, correctional rehabilitation workers and custody staff.
Male detainees may be admitted to 2North, the 24-bed acute psychiatric unit, from intake, general population or other mental health units. Primary reasons for admission include an acute risk for haim to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for victimization in other living units. Detainees housed on 2North are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2North for a brief period of time before transitioning to a less restrictive setting.
The subacute mental health unit, 2South, is a 26-bed unit for detainees that have demonstrated a decrease in the severity of psychiatric symptoms but continue to evidence symptoms that cannot safely and adequately be treated in a division with mental health services. Some detainees exhibit chronically severe symptoms that necessitate long term sheltered housing. They may be housed

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on 2South or 2East, a 12-bed unit that houses detainees that demonstrate severe negative symptoms of psychosis, chronically severe depression and/or significant cognitive delays.
Discharge Planning
Cermak male mental health units are staffed with 1 Medical Social Worker who maintains regular contact with detainees diagnosed with serious mental illness to coordinate post-release treatment services in the community. Due to the severity of their mental illness, all detainees released to the community from these units must be assessed by a Qualified Mental Health Professional prior to discharge to determine the need for hospitalization. If community hospitalization is not warranted based on the clinical assessment, the Medical Social Worker can assist the detainee with referrals to community agencies for continued treatment and shelters for housing. The Medical Social Worker can also arrange for the detainee to be given a 2-week supply of his current medications.
Cermak F'emale Acute and Chronic Mental Health Unit Description
The Cermak female acute and chronic mental health unit, 2West, is a 20-bed unit devoted to the psychiatric stabilization of detainees whose presentation warrant stabilization and/or extended observation. Detainees may be admitted to 2West from intake, general population or other mental health units. Primary reasons for admission include an acute risk for harm to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for victimization in other living units. Detainees housed on 2West are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2West for a brief period of time before transitioning to a less restrictive setting unless they present with symptoms that warrant chronic care services. Chronically mentally ill detainees that require continued housing on 2West demonstrate severe negative symptoms of psychosis, chronically severe depression and/or sigrcificant cognitive delays that cannot safely and adequately be treated in a division with mental health services.
Discharge Planning
The Cermak female mental health unit is staffed with 1 Medical Social Worker who maintains regular contact with detainees diagnosed with serious mental illness to coordinate post-release treatment services in the community. Due to the severity of their mental illness, all detainees released to the community from this unit must be assessed by a Qualified Mental Health Professional prior to discharge to determine the need for hospitalization. If community hospitalization is not warranted based on the clinical assessment, the Medical Social Worker can assist the detainee with referrals to community agencies for continued treatment and shelters for housing. The Medical Social Worker can also arrange for the detainee to be given a 2-week supply of her current medications.
April2016 Cermak Status Update

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Psychiatric coverage of the Psychiatric Special Care Units has been without changes. 2N is covered by 1 FTE Psychiatrist and 1 FTE Psychiatric PA. 2W/2S/2SE are covered by 1 FTE. 2E is covered by 0l.FTE. Treatment Compliance Incentive Program has also positively impacted the overall milieu Dr. Waxler (Unit Director for 2N/2W) continues to provide supervision to staff. Dr. Nunez provides supervision to staff on 2S/2E. Increase in efficiency and better adherence to the statutory deadlines for UST removal to the DMH has led to fewer delays for 2S/2SE detainees awaiting their turn to go to the DMH. Supt. Jones continued to facilitate hygienic procedures in coordination with Nursing and MH staff.
PSCU Executive Summary
2N (males) and 2W (females) are Special Care Units within Cermak Health Services that provide psychiatric/mental health services to a population of acute, sub-acute, and chronic individuals. A psychiatrist meets with each patient within 24-hours of admission and then daily thereafter. Structured group programming i's delivered daily to patients, which ranges from a "Rise and Shine" group focusing on hygiene/ADLs, to "Community Meeting/Unit Orientation," as well as more clinically focused groups.
Clinical groups take place both in the day room and in the small group room and generally engage patients in discussing topics such as Anger Management, Coping Skills, Patient Rights, Understanding Mental Illness, etc. The Rise and Shine Programming typically runs from 08301000. Two clinical groups are generally conducted between 1000-1230, or until patients are returned to their rooms. Groups resume after patients are allowed out of their room for the afternoon, typically between 1730-2000. An expressive art therapist also spends between 68/week providing small group sessions to patients on both units Mondays- 2W, Thursdays 2N). All services are provided by licensed Mental Health Specialists (MRS-III). Patients housed on the Special Care Units are seen by a Mental Health Specialist during rounds on each shift, and they have access to a licensed Mental Health Specialist 24 hours a day. Mental health staff engages patients either in their room or in the milieu (dayroom or interview room). Patients also have access to psychiatric services while housed on the Special Care Unit. They typically meet with a psychiatrist or physician's assistant daily.
Since October 2015, patients on 2N have been receiving an average of 4.67 hours of structured group programming per day; while patients on 2W have been receiving an average of26.37 hours of stmctured group therapy per week, per patient. These numbers are quite high when patient acc,ess is considered. There are many factors that negatively impact the access mental health specialists have to work with patients. For 2N, patients are being engaged in structured group programming an average of 84.8% of the time they are out of their room over the last six months (October 2015-March 2016). The percentage oflarge group room therapy versus small group room therapy has remained steady at about 90% to 10%, respectively. The majority of small group room therapy has been expressive art therapy groups where patients have the opportunity to listen to music of their choosing, write letters with a provided stamped envelope, create art with markers, write poetry, and look up words in a dictionary.

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Another challenge to providing groups in the small group room is the creation of a secure environment by having a proximate officer. This is not always possible in such a dynamic environment (examples of conflicting activities include: medication pass, psychiatry evaluations, crisis interventions, and movement off unit). Staffis working towards increasing the amount of small group room therapy provided each month by collaborating with CCDOC partners in order to have the: groups properly supervised.
Access to patients has been tracked on 2 North as our group therapy hours were appearing deflated if it was assumed that staff had 12-14 hours of access to patients. Over the past six months (October 2015-March 2016) the average access staff has to engage patients in groups is 5.5 hours/day. [It should be noted that CCDOC review of out of cell time found that the majority of the detainees were out of cell for 7-8 hours per day. This discrepancy appeared to be related to CCDOC including inmates on walk-alone status being counted in the out of cell time average.] With the Cermak metric taken into account, our average of 4.67 hours/day of structured group therapy constitutes the utilization of 85% of available time. The remaining 15% of out-of-cell time is used for meals and unstructured recreation (television, phones).
The percentage of group programming on 2N has shown a slight decrease over the past four months which may be related to several factors. One hypothesis is that the MHS staff has been trained to be more consistent with what can be counted as actual clinical group programming. In the past, there was more inconsistency with reporting activities such as socialization/unstructured recreation time as group programming which may have inflated our numbers slightly (October92% and December- 94%). In addition to this hypothesis, we have been seeing an increase in situations that prevent group programming from taking place, such as: patients who have a House Alone/Out Alone or P.C. status, incidents in the milieu (Use of Force, FLR deployment, flooding cell), and maintenance/construction on the unit. The group programming hours will continue to be monitored within the context of how many hours Mental Health staff has access to patients. One proposed solution is to engage patients in groups in the small group room while a P.C. detain.ee is using the dayroom area.
In addition to providing assessment/treatment planning, milieu therapy, rounds, individual sessions, and group sessions, the mental health staff also meets daily in a "morning huddle" to discuss new admissions and any concerns or questions from the previous day(s). Staff will also regularly engage in multidisciplinary treatment team meetings held twice a week on both units to discuss patient progress, update the patients' treatment plan, and address any other pertinent items/issues. The restraint and seclusion log for the previous week is reviewed twice weekly (am and pm shifts) at staffing, and staff is given the opportunity to discuss any issues or questions they have with the process of utilizing therapeutic restraint/seclusion. Multidisciplinary Treatment Team (MDT) meetings are scheduled regularly and consist of psychiatrists, psychologists, physician's assistants, mental health specialists, nurses, and correctional officers.
The two main challenges to the Special Care Units have been related to: 1) lack of patient motivation in the recovery process and 2) maintaining a routine schedule for service delivery.

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Examples of patients with low motivation towards treatment might include patients admitted due to the nature of their charge or patients who are admitted to the Special Care Unit who upon admission deny any symptoms, stating that they manipulated the system for secondary gain (i.e. movement, preferential housing). Patients who are not invested in the recovery process can be disruptive to those who would benefit from a low environmental,stimulation therapeutic milieu.
Maintaining a routine for service delivery is also challenging in an environment with individuals who are labile and more likely to become physically aggressive. Aggressive behaviors by one patient can lead to all patients being directed back to their rooms. Multiple admissions can happen on the same shift which also has the ability to disrupt the ability to deliver group therapy on that shift depending on single room availability and the security status ofthe new admission. In addition, building maintenance and environmental services can diminish patient access to services as some rooms can be decommissioned for issues such as plumbing, painting, waxing floors, etc. Maintenance can be both routine, as well as in response to property or physical plant destruction or for the removal of biohazardous material.
With regards to the milieu and therapeutic environment on the psychiatric special care units, staff works towards developing rapport with each patient and providing a sense of physical and emotional safety. This is especially the case on 2 West (females), where staff provides a more trawna-in£ormed approach to working with patients. Staff encourages patient compliance with treatment while also respecting patients' rights. Mental health staff spends time describing patient rights with regards to medicaVmental health treatments (i.e. right to refuse medications).
The incentive program is utilized on 2 West to encourage patients to participate in healthpromoting activities, such as hygiene, group therapy, and medication compliance. Mental health staff tallies: points and provides incentives for patients who engage in these activities. Mental health staff will modifY the incentive program for patients with special circumstances (such as out alone/house alone status) to make it possible for all patients to participate in the program. A recent rotation of mental health specialist staff has taken place on the 2nd floor of Cermak. The current placement ofmental health specialists was initiated on April!, 2016. This was done to decrease/prevent staff burnout and to increase staff's ability to work in various clinical areas. So far the rotation has been met with mixed reviews by mental health staff. Some staffmembers were opposed to moving, while others welcomed the change. There are normal personnel issues that can be expected in a fast-paced and emotionally charged environment. Burnout-related absenteeism is an issue that is addressed both in individual and group supervision. Since the beginning of2016 one group supervision session per month has been dedicated to selfcare/burnout prevention.
An area that has been improving is cooperation across disciplines. This has periodically been a challenge, but generally has been moving in a positive direction. Mental health specialists are more likely to communicate/collaborate with medical, nursing, and the officers. This collaboration can be challenging at times due to discrepancies between professional perspectives and opinions, but has been improving. The increased collaboration amongst leadership may be

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Appendix IV The Agreed Order Status Update Page 40 of 57

driving this improvement (i.e. regular interagency management meeting and multidisciplinary staffing). In all, the Cermak Psychiatric Special Care Units (2 North and 2 West) provide patientcentered multidisciplinary treatment to a diverse and challenging population.
Please see PDF Appendix (Monthly Statistics 2016) for group programming statistics, which includes the following:
Inpatient Weekly Programming Hours

INPATIENT WEEKLY PROGRAMMING HOURS BY UNIT2016

LOC JAN · fEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC AVE

2N* 4.9* 5.1* 4.4*

4.8"'

2$ 18.9 20.1 19.6

19.5

2E 15.3 18.2 17.4

17.0

2W 25.2 22.5 23.6

23.8

*Cakulated Cl'S DAILY PROGRAMMING· HOURS

INPATIENT WEEKLY PROGRAMMING HOURS BY UNIT2015

LOC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT

2N* 4.5* 4.S.* 3.9* 3.3* 3.7* 4.2* 4.5* 4.7* 3,..9* 3.6*

25 14.3 14.8 1$.6 23.1 21.8 19.8 18.0 1L7 19:1 18.8

2E 13.9 12.8 11.7 1S..2 14.1 12.2

7.1

7.5 i4.1 13.8

2W 23.0 26.0 22.5 27:7 26.2 25.0 23.6 21.8 29.5 31.7

*Calcuftrted ors DAJLY PROGRAMMING HOURS

NOV 4.9'* 1$.0 13,6 26.8

DEC 5.1* 16.6 12.6 28.4

AVE 4.9* 17.:) 12.4 26.1

Cermak Medical Social Workers continue to provide linkage and aftercare planning for SMI detainees 2md P2 detainees not participating in the Mental Health Transition Center Program (CCSO employs its own discharge planners). The Medical Social Workers also continue to be an integral part of the response to calls received by the Sheriff's Care Line. All information related to mental health issues continues to be forwarded to our two senior medical social workers for follow up and/or delegation to divisional social workers if indicated. Since the last visit, our social work staff has addressed 61 calls/referrals. Of those referrals, (64%) had already been identified, evaluated, placed on the MH caseload and were receiving treatment. (8%) of the referrals yielded new additions to the MH caseload, and the remaining (28%) referrals were determined to not be in need of continued follow up from the MH department. This collaborative community outreach effort has resulted in increased access to collateral information and opportunity for improved care and clarification of needs. Please see the PDF Appendix for the broader scope of services provided by Cermak Medical Social Work staff.

Detainees meeting criteria for involuntary admission by petition and certificate are transported to one of two area hospitals (Mt. Sinai and St. Anthony) upon release from Cermak by the court system. All detainees with P4 alert are evaluated at the moment of court release, and those anticipated to meet criteria for involuntary admission in the community are also 'flagged' ahead of time in EMR to ensure that their need for continued inpatient treatment is not overlooked if they are re'leased in the overnight hours. There has been no indication of 'missed' evaluations at discharge recently, and the program continues to be very efficient.

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Appendix IV The Agreed Order Status Update Page 41 of 57

In 2014 and 2015, an average of3.8 patients per month were transported to community hospitals for involuntary admission by petition and certificate upon release from CCDOC. For the first quarter of2016, the rate is 3.0. This decline may be accounted for, in part at least, by the reduction in jail census over the past two years. The average daily population in the jail for 2014 was 9,351. For 2015, the ADP was 8,204. For the first quarter of2016, it is 7,996. This represents a 16% reduction in census, which is close to the 22% reduction in post-detention petitioned and certified hospital admissions during the same period.

INVOLUNTARY HOSPITALIZATION BY PETITION & CERTIFICATE UPON

RELEASE 2014-16

YEAR JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC TOTAL

2016 3 2 4

1

2015 3 7 2

2 3

10 0 3 2 4 6 3 32

2014 3 5 4

4 4

5 5 4 3 4 3 4 48

INVOLUNTARY HOSPITALIZATION

Q1-Q4 2014-16

YEAR Ql Q2 Q3 Q4 TOTAL

2016 9 1

2015 12 15 5

13 32

2014 12 13 12 11 48

Detainees meeting criteria for the administration of involuntary medications (non -emergency basis) continue to be evaluated for filing of the Petition. Some patients refuse to accept psychotropic medications, sometimes even in cases when their safety and survival depends on their receiving treatment. In those cases, judges are petitioned to authorize involuntary treatment. Typically our petitions for the administration of involuntary treatments are heard by the judges at the Circuit Court of Cook County. Cermak's petitions for the involuntary administration of psychotropic medications undergo vigorous judicial review and are not afforded the administrative review process. While preparing these petitions requires many hours ofmedical research and clinical data analysis, this painstaking process is made even more difficult by the fact that Psychiatric Providers have to travel to the Daley Center for the hearings. It was suggested that petitions for the involuntary administration ofpsychotropic medications be heard by Criminal Court Judges at the Leighton Center, thus reducing Cermak's travel and time expenditures. A letter to one ofthe Judges at CCB was written by Dr. Kelner seeking assistance in the matter. Furthermore, Dr. Kelner contacted ASA Office seeking additional information and guidance in finding out if the Harper Procedure afforded to detainees in IDOC ( Administrative review ) can be applied to CCDOC detainees in lieu ofthe Judicial Review that we currently use to petition for the administration of involuntary medications (non-emergency basis).

See PDF Appendix for Correspondence from Dr. Kelner.

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Appendix IV The Agreed Order Status Update Page 42 of 57
CCSO facilitated, 3 joint sessions of CIT training for Cermak clinical staff and custody staff. The first was a 7 hour overview, the others the full 5 day training. Staff persons selected for this initial training are currently assigned to the psychiatric care units or the residential treatment unit. Staff selected to attend reported finding the training extremely useful. So far 12 Cermak mental health staff completed the full CIT training, while an additional 7 attended the initial CIT overvrew.
Following a sentinel event on 2N on 12/01/2015, a staff safety checklist was developed in MH CQI committee meetings and shared with CCDOC and Cermak Leadership. Findings were further discussed in CQI Suicide Prevention Committee meeting. One of the recommendations developed in CQI meetings was to install a retractable physical barrier to separate clinical areas/nurses stations in PSCU's from the space available to detainees for roaming and progranrming. Presently the project is still in the cost estimation phase and has not resulted in a decision to proceed with the installation. Several caveats were also demonstrated, the main being that physi<:al separation of staff from detainees might lead to staff's decreased motivation to participate in therapeutic milieu. It was noted that earlier and more aggressive pursuit of the Petition for the Involuntary Administration of Medications (non-emergency basis) would have been a more viable strategy, given the relative infrequency of similar sentinel events in PSCU. As a follow up to the said sentinel event and other incidents throughout the compound, civilian's staff safety was discussed in Mental Health CQI Meetings. Concerns voiced by front line staff were incorporated in the discussion and relayed to CCDOC Leadership. A checklist of safety issues (some of them impacting delivery of services, including, but not limited to crisis services and therapeutic progranrming in segregation) to be addressed in clinical areas was generated and can be found in the Appendix. The checklist was additionally discussed in Mental Health CQI meeting in April2016.
CCDOC Submitted Updates
Inmates in Cermak (excluding 2North, the acute male unit) are recreated on Thursdays, Fridays and Saturdays outside of programming hours.
2North
The General Population detainees/patients receive time out of cell for a minimum of 7-8 hours per day. Due to the census and high turnover it is hard to state with accuracy how many hours a day Out Alone/House Alone detainees/patients receive. Due to the damage that some inmates cause to the rooms, hours may be minimized by the need to complete facility repairs. At minimum, Out Alone/House Alone and Protective Custody detainees receive 1 hour out of cell each day and are encouraged to participate in progranrming for additional hours out of cell. All activities in regards to security are notated in the Officer's log book.
2South

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The General Population detainees/patients are out of their cells for a minimum of 7-8 hours per day. Prote·~tive Custody and Out Alone/House Alone detainees receive I hour out of cell each day and are encouraged to participate in programming for additional hours out of cell. All activities in regards to security are notated in the Officer's log book.
2East
The census on 2East is usually 8-12. Most individuals come out of their cells for a minimum of 8-10 hours a day. Because the unit is smaller in size and much more manageable, they are allowed the freedom to return to their cells. All activities in regards to security are notated in the Officer's log book.
2West
The census fluctuates considerably on this living unit but usually houses 14-21 detainees/patients. Most of them come out of their cells for a minimum of7-8 hours a day. All activities in regards to security are notated in the Officer's log book.
Inmate Hygiene
DOC, nursing, enviromnental services and mental health staff continue to be proactive with managing imnates with poor hygiene in Cermak. Once a humanitarian shower is requested, all staff work together to accomplish the task.
Apri12016 Metzner assessment: Access to patients by clinical staff, especially on 2N, is limited related to most imnates being locked down generally from 12:30 PM-to about 4:30PM or 5:30PM related to out of cell time for walk alone status inmates. Inmates on this unit generally are out of their cells for 5.5 hours per day. The discrepancy with the CCDOC report of inmates being out of their cell 7-8 hours per day appears to be related to counting hours out of cell for "walk alone" imnates. There was agreement with key correctional and mental health staff that the out of cell hours per day will be increased and will be spot checked on all Special Care Unit patients.
During the morning of April20, 2016 I observed patient activity in all of the Psychiatric Special Care Units. I was impressed with the quality of the activities being offered and the inmate participation. I discussed with Dr. Jones and Dr. Kelner an agreeable process to monitor the amount of out of cell activities generally be offered to all inmates on these units, with a particular focus on Unit 2N.
As in the past, I emphasized the following principles:
1. Out of cell time unstructured time is much better than being locked down. 2. Out of cell structured therapeutic activity is better than unstructured time

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3. There should be a reasonable balance of both out of cell structured therapeutic activity and out of cell unstructured time.

Recommendations: The number of out of cell structured therapeutic activities and out of cell unstructured time on all of these units needs to be increased and monitored.

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with the mental health caseload roster listing the

inmates currently receiving mental health care.

Assessment: Substantial compliance (since June 2012)

November 2015 Metzner assessment: Substantial compliance continues.

April2016 Metzner assessment: No change

j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when
punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status.

Assessment: Substantial compliance continues (since October 2012).

Factual Findings:

April2016 Cermak Status Update

Based on the results of interagency collaboration, the 14 day stipulation was removed, DOC understands that if mitigating factors are identified and there is no contraindication for continued placement in disciplinary segregation they will limit disciplinary segregation time for P3 and P4 detainees to 14 days or less.

Following the dismantlement of the Levels System, a combined huddle meeting for Compound Disciplinary Segregation! Restrictive Housing Units analogous to The Levels System Meeting (for Administrative Segregation) takes place on a weeldy basis. It was decided that these discussions are to occur at the Leadership Level/ Cermak MH Administration level and not during local divisional management meetings. Cermak MH Leadership (Drs. Key and Kelner)

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AppendixN The Agreed Order Status Update Page 45 of 57

discontinued reviewillg the cases of detainees housed in Special Incarceration Unit to provide the higher level of review. The said Unit is no longer a part of the Levels System.

Please see PDF Appendix for Mitigation Report.

CCDOC ~ ~ubmi'tted Um•dates

Division 1 Division 2 Division 3/4 Division 6 RTU

Janua

Total Written

9

61

26

355

Psych Consults

0

0

0

0

Mitig;~tions

CHS
122
"'

February Total Written Psveh Consults Mitigations

48 0

" 0

36 0

349

82

0

33

March Total Written Psych Consults Mitigations

41

,.

319

166

0

0

0

Z7

Division 9 Division 10 Division 11 Division 17 Totals

22

268

163

11

39

0

0

0

10 1047

0

77

32

63

206

246

57

24

0

0

0

so

280

223

53

26

0

3

0

1125 57 29
1110 56 26

Of the total number of disciplinary reports written, approximately 5-7% are referred for mental health mitigation review. Of those referred for mitigation review, approximately 45% of them are deemed to have mitigating factors. From January to March 2016, the typical consequence given by the hearing board was time in disciplinary segregation, much of which was less than 15 days. All of the detainees with mitigating mental health factors were either housed in Cermak or Division 0:8 RTU. Detainees housed in the Cermak mental health units do not complete disciplinary segregation time. They are allowed out of their cells for programming, so they typically engage with mental health staff and/or other detainees on the unit for 7-8 hours each day. Detainees housed in Division 08 RTU segregation units receive regular programming from Cermak mental health staff.

April2016 Metzner assessment: Substantial compliance continues

k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.

I. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with

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Appendix IV The Agreed Order Status Update Page 46 of 57
appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Substantial compliance (11115)
Factual Fiindings:
April 2016 Cermak Status Update
CCDOC Administration brought in the State ofiL statutory compliance their disciplinary segregation process and, presently, detainees' stay in disciplinary segregation cannot exceed 29 days, whereupon, they are removed from segregation and undergo additional review in order to determine whether they need to be put back in segregated setting. Mental Health Department continues to provide 24 hour segregation screening for this cohort of detainees reentering restrictive settings.
Mental health staff continues to conduct rounds on restrictive housing units at minimum weekly. Dr. Key and Dir. Lyles collaborated to update the currently used SMU notification sheet to include originating in addition to proposed housing change to address what is suspected to be an artificial lowering of screening compliance. Detainees moving from one segregation tier to another are not in need of additional screening, however are documented on the notification sheet for institutional purposes. Mental health, unable to differentiate between those who were in need of a screen from those who are not, count the compliance rates at face value. As such, both agencies are confident that the screening compliance rates are higher than the data currently reflects. The new notification sheet will be distributed and used by all divisions. Please see Excel Appendix SMU Screen.
CCDOC Submitted Updates
The Department of Corrections has been 100% compliant with the daily notifications to Cermak of detainees placed in disciplinary segregation since January 2016. In December 2015, the CCDOC Executive team increased the accountability of divisional Superintendents by requiring divisions housing disciplinary segregation tiers to maintain monthly calendars noting the staff member that made the daily notification to Cermak. If notification was not made, disciplinary action was initiated. In October 2015, the DOC initiated the Placed in Segregation alert in CCOMS as an additional method to notifY Cermak of all detainees placed in segregation. In

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AppendixN The Agreed Order Status Update Page 47 of 57
March 2016, the centralized classification unit took responsibility of entries and discharges to segregation units. This measure increases the oversight of the process and maximizes consistency across divisions.
April2016 Metzner assessment: Substantial compliance continues
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
Compliance Assessment: Substantial compliance (4/16)
Factual Fitndings:
April2016 Cermak Status Update
A restraint audit QI report, completed by the Cermak nurse manager, Madonna Mikaitis, R.N. was reviewed and demonstrated compliance with the relevant policy and procedure.
An audit regarding Notifications to the Facility Director was undertaken that demonstrated issues in the reporting process, which hare in the process of being corrected.
April2016 Metzner assessment: Substantial compliance has been achieved.
Recommendations: Continue with the current QI process.
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
Compliance Assessment: Partial compliance
Factual Findings:

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Appendix. IV The Agreed Order Status Update Page 48 of 57
April2016 Cermak Status Update
The collection of the HSRF response data reflects face to face evaluations conducted by mental health specialists by level of ordered priority (see Excel Appendix). Compliance with responding to all HSRF with a face-to-face evaluation within the required timeframes has continued to show improvements, specifically in response to Urgent and Priority health services requests. Currently approximately 95% of the Urgent HSRF are seen on the same day that the request is received and close to 90% of requests deemed a priority are seen within 48 hours of receipt of the request. While this trend is encouraging, response to routine requests continues to fall below expectations with approximately 70% of routine requests for services being seen within 72 hours of receipt of the request. One !mown factor continues to be delayed scheduling of appointments related to staff allocation and staff attendance. The second full-time mental health specialist that was previously assigned to Div. 9, one of the problematic areas, had to be reassigned to Div. 10 due to compound housing changes and reassignment of mental health patients. Unfortunately, despite the decrease in mental health patients in Div 9, mental health has not noticed a decrease in HSRF needing a mental health response. Female services has been short two licensed mental health specialists for an extended period of time, which has made adherence to HSRF timeframes more challenging. Other areas are impacted by staff absenteeism and sheer volume ofHSRF submitted. There are just far more patient requests for services than we have the staff to respond to in the required time frames. As such, clinics fill up quickly and appointments are scheduled further and further back. We incorporated these issues into our proposed staffing plan for the 2017 budget cycle, as expect that that we would see improvements in response time with increased staff numbers. As a department we continue to discuss ways in which to address the challenges associated with responding to repetitive and misused requests (i.e. detainees who fill out numerous requests for secondary gain). We also expect that as the protocols and procedures for the processing ofHSRF becomes more fluid within Cermak as a whole; the mental health response time will improve. Patient Care Services staff continues to be provided education as to the appropriate handling of HSRF for mental health services. Cermak leadership is also engaged in discussion with the IT department about updates to the documentation of mental health HSRF in the medical record that would allow more efficient documentation of face to face triage by the QMHP and minimize "missed data" that is interpreted as a patient not being seen when that may not have b<een the case.
There is diminished concern regarding the number of HSRF that were classified as "not seen" by absence of documentation reflecting an evaluation in the medical record. The number in this category has not only significantly decreased in comparison to prior visits, but review of the records reflect that most of the HSRF had either been responded to by a QMHP, however the response was documented within the HSRF ad hoc document in the EMR which is not currently captured by the data . This is being addressed with IT. Remaining "not seen" were due to patient refusals and erroneous referrals to mental health that were not mental health related and did not warrant a mental health evaluation. The Chief Psychologist will monitor "Not Seen" patients to ensure access to care is consistently and appropriately provided.

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To expand the availability of crisis response to divisions, additional telehealth equipment was installed in the urgent care. With this additional equipment, when there are two mental health providers scheduled to the urgent care, divisional services needs have increased access. This has been of specific benefit with regard to screening the often high numbers of individuals that enter segregation on a daily basis.
Apri120115 Metzner assessment: QI data documents issues in meeting tirnelines for responses to routine mental health referrals related to the current policy and procedure that requires a face to face triage for routine referrals within 72 hours and periodic delays in receiving the referral from nursing staff in a timely manner. I discussed with staff potential revisions to the pertinent policy and procedure that will significantly decrease the lack of compliance. In addition, the process involved with the sending of the mental health referrals from the nursing staff to mental health services needs to be improved.
Recommendations: As above. Refer to the medical monitor's report.
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cennak shall ensure that 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.
Compliance Assessment: Partial compliance
Factual Findings:
April 2016 Cermak Status Update
Periodic monitoring of blood levels of Lithium and Depakote is important for the safe administration of the said medications. It is suggested that blood levels are checked at least every 6 months, even if a patient remains asymptomatic and the dosage remains unchanged. A new Cemer ale1t was created. The logic now exists in EMR and, when Providers (both Medical and Psychiatric:) try to order and, more importantly, reorder Lithium and Divalproex, a new rule fires. If no Li and VPA levels have been ordered over the past 6 months, it prompt the system to order Li and VPA levels. Presently, Chief of Psychiatry proposed that a similar alert be created to ensure timely monitoring of blood glucose levels and lipids against the backdrop of the

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AppendixN The Agree:d Order Status Update Page 50 of 57

administration of second generation antipsychotics. As demonstrated by the chart, the frequency of medication monitoring has reached levels above 90%.

AS of 4 7 2016 Lithium
Divalproex Sodium/ Valproic Acid

#of Med Order(person) 20 193

#of Lab Order 20
180

Risperidone/ 539

240

Ziprasddone/

Olanzapiae

Ratio 100% 93.26%
44.53%

April2016 Metzner assessment: As above.
Recommendations: Develop and implement the careset for blood glucose levels and lipids studies.
E. SUICIDE PREVENTION MEASURES
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged wiith developing policies and procedures to ensure the appropriate management of suicidal inmates and wiith implementing and monitoring a suicide prevention program in accordance wiith generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. The suicide prevention policy shall include, at a minimum, the following provisions:
(1) an operational description oHhe requirements for both pre-service

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Appendix IV The Agree:d Order Status Update Page 51 of 57
and annual in-service training; (2) intake screening/assessment; (3) communication; (4) housing; (5) observation; (6) intervention; and (7) mortality and morbidity review.
Compliance Assessment: Substantial compliance (November 2013)
Factual F1indings:
November 2013 Metzner Assessment: Significant improvement is noted in the Mortality & Morbidity Review reports, which are now using a root cause analysis format.
As described elsewhere in this report, problems remain relevant to the intake screening/assessment process, especially in the context of priority referrals and segregation admissions screening. These issues are addressed elsewhere in this report.
April2016 Cermak Status Update
Four reports were submitted for review, following initial Root Cause Analysis. One RCA was following staff assault (patient's initials are PD). Two RCA's followed completed suicides (JS and DL). One RCA followed a critical incident on 2N unrelated to suicide and self-harm (AC). Cermak cr,eated narratives with a summary of relevant findings for the RCA related to the staff assault, two completed suicides and the critical incident. It is of note that, according to the IL statute, presently, deaths in custody are investigated as potential crimes by IL State Police Task Force and no results of their investigations have been made available to Cermak. As of the submission of this report the following datal action items and relevant findings have been reviewed in Suicide Prevention CQI: staff assault (PD). The following RCAs were reviewed in Mental Health CQI (JS, DL, and AC). Final autopsy results for all RCAs were unavailable at the time of this report. Two RCAs following staff assault, completed suicides and the critical incident in Cermak were conducted with CCDOC participation according to the timeframes (1 0 days).
CCDOC Submitted Updates
In 2015, the Illinois General Assembly passed SB1304, the Police and Community Relations Improvement Act. The Act requires law enforcement agencies to employ an outside law enforcement agency to investigate all deaths involving officers. In January 2016, the DOC began utilizing the Illinois State Police Public Integrity Task Force (PITF) to investigate all in-custody deaths, including detainee suicides.

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April 20116 Metzner assessment: Substantial compliance continues
62. Suicide Precautions
a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.
c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored witll:t constant direct supervision until the inmate is transferred to appropriate Cermak staff.
d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:
April 2016 Cermak Status Update
The language in Cermak Policy GOS A#10 was amended in order to clarify Cermak's Suicide Prevention Program:
A#8. It wa:s confirmed via CCHHS Risk Management and legal research that the original Policy language allowing QMHP (including licensed MHS III's) to increase level of observation and order close observations was consistent with NCCHC standards and IL Nurses Practice Act.
A#l 0. The following rules now apply to renewing and downgrading suicide precautions: Psychiatrists and a doctoral-level Mental Health Clinicians (Psychologists) may downgrade or discontinue suicide precautions after an in-person evaluation. A physician, other than a psychiatrist, may downgrade or discontinue suicide precautions only after conferring with a psychiatrist. Hitherto, only Psychiatrists had been able to downgrade/discontinue the level of

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Appendix IV The Agreed Order Status Update Page 53 of 57
observation. Interagency CCDOC/ Cermak Suicide Detection and Prevention 64.9.22.0 D-2 also asserts that Psychiatrist and Psychologists may downgrade or discontinue observation status.
See PDF Appendix for Suicide Detection and Prevention QI Report Qtr. 4 2015 and Qtr. 1 2016 and Self- Injury Data (Mental Health Monthly Statistics).
April20115 Metzner assessment: Substantial compliance continues
64. Suicide Risk Assessments a. Cermak 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. b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record.
Compliance Assessment: Substantial compliance (11/13)
Factual Fiindings:
November 2013 Metzner assessment:
The 15 charts in the EMR of patients, who had screened positive on the suicide screen, were reviewed by my fellow in forensic psychiatry. These charts were randomly selected among approximately 40 patients who had screened positive on the suicide screen. Every patient chart reviewed had a secondary suicide risk assessment completed. In 12 of the 15 assessments, the form was c:ompleted and the narrative summary was consistent with the checked items. In three of the assessments, the narrative summary was thorough, but risk factors highlighted in the narrative summary were not checked as risk factors in the body of the assessment form. This was likely an error because the narrative summary assessed those patients as a risk for suicide.
April2016 Metzner assessment: Review of relevant QI data demonstrated continued substantial compliance.
65. Cermak shall ensure that inmates will only lbe removed from Suicide Precautions aft1~r a suicide risk assessment has been performed and approved by a Qualified

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Appendix IV The Agreed Order Status Update Page 54 of 57
Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Hf:alth Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11/15)
Factual Findings:
Novembe1r 2015 Metzner assessment: Review of the relevant QI results were consistent with the presence of substantial compliance.
April201<~ Cermak Status Update
Please refer to QI reports referenced in provision #62.
Apri120115 Metzner assessment: Review of the relevant QI results were consistent with the presence of substantial compliance.
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Qmality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
Compliance Assessment: Substantial compliance (11115)
Factual Fiindings:
Apri12016 Metzner assessment: The pre-site information packet, which included the QI appendix, was well done and extremely helpful. The QI studies were methodologically sound, well written and very reievant.
Additional Information

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AppendixN The Agreed Order Status Update Page 55 of 57
Apri1201'6 Cermak Status Update
Use of Fo~rce Task Force and Tracker.
The CCDOC and Cermak are committed to ensuring that uses offorce against the seriously mentally iU are rare and consistent with our UOF standards. To this end, we have:
• continued to emphasize to CCDOC and Cermak staff the need for effective de-escalation attempts;
• sent over 60 correctional and mental health staff working with these populations to statecertified Crisis Intervention Training (with plans to send more in May and then throughout the year);
•continued to provide over two weeks of Advanced Mental Health and Crisis Intervention Training to all correctional officer recruits;
There has been a relatively significant decrease in the collective monthly average uses of force by those who attended the training.
•required that all CCDOC staff take the on-line "Advanced Mental Health Training" course by April3, 2016 (will provide copy during site visit upon request);
• modified the interagency daily huddle format so that CCDOC has consistent representation and tracks relevant UOF information more quickly and uniformly;
• since December, Cermak and CCDOC representatives have met monthly as an interagency group specifically to assess the individual and collective uses of force against P-3's and P-4's and resolve UOF issues;
• ensured that there is 24/7 Mental Health staffing in Cermak and RTU
• submitted a staffing plan to CCHHS that calls for increased mental health staffmg.
•continued to refine and improve upon the sharing of pertinent medical documentation between Cermak and the UFRU --there have been no issues or problems reported for several months;
•created an electronic Dashboard of all uses of force to better detect key trends;
• added staff and resources to the UFRU to ensure quicker assessments ofUOF's involving p-3's and P-4's; and

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Appendix IV The Agreed Order Status Update Page 56 of 57
•remained committed to expanding the Intensive Management Unit for some of the most problematic P-3 inmates.
In addition, Superintendent Jones and Cermak Leadership have helped usher in an improved culture of sensitivity and accountability within all disciplines working the znd Floor of Cermak. Last month, there were 8 uses of force, which was the lowest since November, and 4 of those 8 involved one patient, JH. We recognize that Dr. Metzner cautioned that any time 0/C spray is used more than 5 times a month, there might be underlying problems. This relatively high number of uses of force involving 0/C has occurred in two successive months. JH was involved in 4 0\C uses. However, at this point, the CCDOC can say with confidence that officers and sergeants assigned to the 2"d floor of Cermak understand that 0/C should be used as a last resort after de-escalation efforts proved ineffective and when it's the safer alternative to going hands-on.
To decrease uses of force and improve operations in the RTU, CCDOC added a Commander and Lieutenant to the evening shift, when a majority of uses of force occur. In addition, CCDOC added an additional sergeant to each shift. This supervisory staffing increase will help with the consistency ofleadership in the division and communication among supervisors from the 7-3 and 3-11 shifts. Supt. Brown and RTU leadership have regular meetings with the psychologists assigned to the 4th and 5th floors to develop behavioral plans for problematic inmates. Looking at patients like MC and WK., these meetings and plans have proven successful in reducing uses of force. Further, CCDOC Executive staff recently met with daytime supervisors in RTU to hear and act upon their recommendations for improving operations. One result is that RTU now has radios playing during non-program hours on the living units. The patients appreciate this, and more analysis needs to be completed to determine if this has been at least partially responsible for a decrease in incidents.
Additional Quality Materials available in the Appendix or During Site Visit: Telepsychiatry Utilization and chart audit Intake Psychiatry Referrals chart audit Facility Director Notifications chart audit CQI Frequency of contact with Providers in Cermak Quality ofRCDC Mental Health Assessments Treatment Plan Audits for each Level of Care
April2011) Metzner Assessment: I discussed issues with key mental health and correctional staff re: the above information. I recommended that they talk with Kathleen Allison (Director Division of Adult Institutions, California Department of Corrections & Rehabilitation) regarding the CDCR response to similar issues.
During the afternoon of April21, 2016, I observed the mental health rounds in the two segregation units within Division IX. They were well performed by the mental health specialist. Six inmates were in the dayroom at a time for 90 minutes with increased correctional officer

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Appendix IV The Agreed Order Status Update Page 57 of 57
present. The inmates were also handcuffed.
This increased out of cell time in segregation units is part of the CCDOC plan to gradually increase the recreational time for segregation inmates to three hours per day. The positive change in the milieu related to the increased out of cell time was very apparent. In addition, the custody staff is providing limited correctional programming on a weekly basis to inmates who are willing to participate. The plan for increased out of cell time for all segregation inmates and the opportunity to recreate with other inmates are very progressive measures and will contribute to less health care issues for these inmates. Mental health services are planning to also provide progranuning to segregation unit inmates if increased staffing allocations are obtained.

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AppendixV

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Appendix V Re: Document requests Page 1 of3
Please have the following information available in hard copy at the time of the site visit, and sent to m1~ one week prior to the site visit in electronic form (but not in PDF) unless indicated otherwis€,, Each piece of information should cover the period since the last site visit.
Note: If any of the requests are too burdensome to produce, please contact me before attempting to produce such information.
Appendh' I Agreed Order 5/13/10 MH provisions revised
Using the word version of Appendix IV in my last submitted report, after each of the "recommendations" section add the following section: [date of site visit] Cermak status update: 2md complete a narrative with proof of practice as available. This document request is the most crucial document. Please do not delete my April 2016 findings or recommendations exceptfor provisions that have beenfound in substantial compliance for at least 18 months..
Some of the following requests may be in the above document and only need to be referenced-it does not have to be provided twice.
Mental Health System
1. The mental health system organization chart (with both position and name ofperson filling the position and his/her credentials- e.g., degree).
2. Any new policies and procedures relevant to mental health services.
3. Any new program descriptions of the current mental health system.
4. Any other reports (i.e., internal or external reviews) relevant to the mental health system at CCDOC.
Institutional Program Status
1. Narrative summary of program status
Staffing
1. List authorized mental health staff positions by discipline (psychiatrists, psychologists, social workers, nursing staff, clerical staff, etc.) and by program/area (intake, crisis stabilization, mental health housing units, etc.). For each position, indicate the person's name, professional degree, start date, and percent ofFTE if not full-time. Ifthe position is vacant, provide the date it became vacant. For any staffon leave, indicate the date the leave began.

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Appendix V Re: Document requests Page 2 of3
2. List any newly allocated mental health positions and the dates they were established.
Census/Mental Health Roster
1. The total number of inmates in the jail, total number in segregation units, total number of mental health caseload inmates, and total number of inmates in each program area (crisis observation, mental health housing, general population, etc.).
2. Statistical information pertinent to the reception center screening of inmates (i.e., number of persons on a daily, weekly, or monthly basis for the past six months, percentage of inmates who have positive screens from a mental health perspective, percentage of inmates with positive screens who enter the continuum of mental health services, percentage of all newly admitted inmates who enter the continuum of mental health services).
Access to Higher Levels of Care
1. Number of inmates admitted to the infirmary on a monthly basis and the median length of stay in such beds.
Disciplinary Reports
1. The total number of disciplinary reports written in the jail.
2. The total number of disciplinary reports v.Titten for mental health caseload inmates in the jaiL Please list by mental health housing wings by Division.
3. The percentage of disciplinary reports that assessed mitigating circumstances to be present.
4. An analysis of the impact of positive mental health assessments re: mitigation.
Quality Improvement
1. Agenda and minutes of all CQI meetings. 2. Agenda and minutes of all Mental Health Subcommittee of the CQI meetings 3. A '~opy of each relevant QA/QI audit conducted, preferably in electronic forms. For each
audit provided, a description of:
a. Statement of the issue being studied b. Methodology used c. Results d. Assessment of results e. Plan of action based on the assessment

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Appendix V Re: Document requests Page 3 of3
Medication management
I. Li:st of inmates and/or logs or other documentation of inmates rece1vmg medications on an involuntary basis.*
2. Audits or other documentation oftimeliness ofmedication delivery to inmates who arrived at the institution with current psychotropic medication orders or adequate verification of current psychotropic medication usage.
3. Audits or other documentation oftimeliness ofmedication delivery upon expiration of prior psychotropic order.
4. Audits or other documentation of practices identifying patients noncompliant with their psychotropic medication (as defined in policy), timeliness of referral to mental health, and timeliness and adequacy of psychiatric response.
5. Audits or other documentation of laboratory testing orders as per standards for psychotropic medications, timeliness of results, timely notice regarding abnormal results, and appropriate medication adjustments.
6. The total number of mental healthcare caseload inmates prescribed medication.
Suicide Prevention
1. For any completed suicide, a copy of the mortality and review report.
2. Agenda and minutes of Suicide Prevention team meetings
Additional Items
1. Schedule of group therapies/structured out of cell therapeutic activities offered to imnates in the mental health housing units.*
2. Logs showing the use of restraints and seclusion, including the dates and times the orders were iuitiated, renewed, and discontinued, and the timing of nursing checks conducted.*
3. Audits relevant to the mental health screening and rounds in the segregation units.
4. Description of the statns of any new construction or remodeling for mental health treatment space.
*Does not need to be sent in advance ofsite visit.

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USA v Cook County, et al. Page 9 of9
Appendix VI

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P3 &TID Charts and Patient Data
Patient #1: R. W. Identifying Information: Patient is a 46 y/o F with history of psychosis, previously a P4 while incarcerated in 2015, and history of treatment at Elgin, re-incarcerated on March 18,2016.
Inten'al History: Patient was seen by mental health on March 19,2016. She was transferred to the PSCU because of paranoia. She was discharged from 2W to IntemLediate Psych on April 1".
Psychiatry Visits: March 19th: Dr. Howard saw her and patient refused medications. He ordered Zyprexa 10 mg bid and pm Ativan, Haldol and Benadryl. He diagnosed her with Psychosis. This remained her diagnosis in subsequent encounters. March 22"d: She continued to refuse medications and refused to interact with Dr. Howard. March 24th: Patient observed to interact with peers many hours of the day and continued to refuse to speak to staff. Dr. Howard changed her to P3 and discharged to RTU. March 25th: Returned to 2W given an error in classification. She was taking 50% of medications. March 28th: Remained on 2W but was now medication compliant. She continued to be uncooperative with Dr. Howard and staff. March 29th: Seen by Dr. Howard, med compliant about 80% of the time March 30th: Taking Zyprexa 10 mg only in the morning. March 31'1: No changes Aprill: Discharged to RTU. No other psych appointments noted.
Group and Individual Counseling: Notes were in EMR for April6, 8,10,12,14,17,18,19. Pt refused a community meeting and psychoeducation on April 6. Pt refused individual counseling on April 8. She attended Rise and Shine and Medications on April 10. She refused coping skills group the afternoon of April 12. Offthe tier on Aprill4. Went outside for recreation on April 17. Attended Rise and Shine/Medications group on Aprill8. Refused groups on April 19.
Assessment: In general, patient received an appropriate level of psychiatric and mental health treatment since her arrival to the Cook County system. However, the lack of psychiatric follow-up since transfer to the RTU is very problematic.
Patient #2: A. V.

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Identiifying Information: Patient is a 51 y/o F with hlo remote inpatient psychiatric hospitalization, past outpatient psychiatric contact but unclear diagnosis, incarcerated on November 8, 2015. This was her first incarceration.
Intenral History: Patient was first assessed by mental health on 11/10/15. She had submitted an HSRF while housed in Division 3. She stated that she was depressed and wanted medications. She was seen by MH again on 11115 after patient submitted HSRF asking when she would see MH again. She was assessed by Dana Laughlin on 11117 and reported increased depression, SI and past psychiatric outpatient treatment and psychotropic trials. Ms. Laughlin referred patient to psychiatry. She was seen by Dr. Menezes and he referred patient to RTU. Patient was subsequently transferred to 2W on 1/8 after disclosing a recent overdose with hoarded medications. She was discharged back to RTU on 1111. She was re:-admitted to 2W on 3/4- after ingesting shampoo and lotion after an upsetting court date. She was discharged on 3/9 back to RTU. She was readmitted to 2W on 3/30 after cutting herself with a metal piece of handcuffs while in court. She was subsequently transferred back to RTU on 4/1.
Mental Health Contact: 11/19: Seen by Ms. Laughlin again in response to HSR and patient asked when she would see psychiatry. 11/23: Seen by Ms. Adame in response to HSR in which patient asked when she would see psychiatry. 11125: Seen by Ms. Laughlin in response to HSR. Pt noted to be odd, disorganized and with poor hygiene. 12/1: Seen by Linkage. 113: Seen by Ms. Adame after security requested contact because pt endorsed SI.l 114 Seen by Ms. Adame for follow up. 116: Seen by Ms. Adame after submitting HSR in which patient said she was slowly dying from a suicide attempt. Ms. Adame agreed to meet with patient the following day. 1/7: Patient told Ms. Adame that she had hoarded medication and overdoses on 1/5. This infom1ation was relayed to the unit director/tier officer. 3/3: Seen by MH after observed drinking lotion and shampoo in the bathroom and making suicidal statements. 3/16: CCDOC requested a MH Assessment because patient was upset about "fraud" in police report. 4/10: Seen by MH because patient stated she was going to kill herself. She had gauze in her mouth and threatened to swallow it. She subsequently calmed with therapeutic interventions.
Psychiatry: 11125: Seen for first visit by Dr. Menezes. Reported increasing depression since early November after suffering multiple psychosocial stressors. Her first incarceration and recently lost job as paralegal. She was diagnosed with Anxiety Disorder and Depression and started on Zoloft 50 mg daily and Benadryl 50 mg at bedtime. She was referred to intermediate psych.

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1211: Dr. Menezes saw patient. She stated that she felt calmer and more relaxed. Current meds were continued. No change in diagnoses. 1/8: Seen by Dr. Howard upon admission to 2W due to recent OD on hoarded medications. Patient's diagnoses and medications were unchanged. 1/11: Discharged from 2W. 2/22: Seen by Dr. Menezes. Patient reported doing well. Diagnoses unchanged. Medications continued. 3/3: Admitted to 2W after ingesting lotion/shampoo with SI. 3/4 Seen by Dr. Howard. He believed that patient also showed evidence of thought disorder and exhibited overvalued ideas. He added Geodon 40 mg at bedtime to her Zoloft/Benadryl. 3/7: s,~en by Dr. Kelner. Patient improving, increased Geodon. 3/8: s,~en by Dr. Kelner. Noticed ongoing signs of thought disorder. Continued medications. 3/9: Seen by Dr. Kelner, discharged to RTU. 3/30: Seen by Dr. Howard upon admission to 2W. Was agitated and tried to harm self while at court. She received emergency medications. 3/31: Patient refused to speak with Dr. Howard. 4/1: Patient more interactive. Discharged back to RTU.
Groups and Individual Counseling: 11127: Attended exercise and medications groups 11128: Attended medications. 11129: Attended Rise and Shine, Medication Compliance and Healthy Living. 1211: Attended multiple groups. 12/2-9: Attended daily groups. 12/31: Individual counseling. 12/10.. 1/7: Attended daily groups. 118-111: On 2W 1112-1/30: consistently attended groups 2/9: Seen for individual counseling with Ms. Adame 2/1-2/29: Attended groups consistently. 2/23: Individual counseling. 3/21: Individual counseling 3/9-4/20: Attended most groups, intermittent refusals. 3/24: Seen by psychology clinic. 4114: Seen for individual session.
Assessment: Overall, patient received an adequate level of mental health services except for untimely psychiatric appointments. Groups and individual sessions were offered routin,sly. She was seen numerous times by mental health in response to requests from staff and/or patient herself. However, there was at least one time in which she was not seen by psychiatry within a 4 week period. She was seen in 5 weeks vs. 4 weeks by psychiatry after her first discharge from 2W to RTU (1111 discharge and seen on 2/22). She was last discharged from 2W on 4/1 and has not yet seen psychiatry (20 days ago) but has been seen for an individual session. One suggestion would be for patients who are

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recent discharges from 2W to be seen by psychiatry within 2 instead of4 weeks upon their transition back to RTU. If that is not feasible, perhaps they could have an individual session within 7 days of their discharge from RTU. This may decrease the return rate back to an inpatient level of care. RTU psychiatry notes did not note when a patient was expected to return to clinic. Minimal rationale included in the plans, so it was difficult to follow the course of treatment and targets of intervention.
Patient #3: D.F Identifying Information: Patient is a 46 y/o M with history of mood disorder, interrnittently taking psychotropic medication in the co=unity, incarcerated on November 4, 2015.
Interval History: Patient was seen by Dr. Ramie in psychiatry upon intake into the jail on 1114. She referred him to the RTU and started him on self-reported meds ofProzac and Riisperdal, which he had not been consistently taking as an outpatient.
Psychiatry: 11/4: Saw Dr. Ramie on intake into jail and restarted on meds and referred to the RTU. 12/24: Seen by Dr. McNeal. Diagnosis of mood disorder and cannabis abuse. Follow up for 4 weeks. Continued medications as prescribed. To consider P2. 2/3: Seen by Dr. McNeal. Ongoing diagnoses of Mood Disorder and Cannabis Abuse. Increased Risperdal to 2 mg. and Benadryl added. 3/10: Seen by Dr. Marri. Recommended £'u in 4-5 weeks. No med changes. 4/14: Seen by Dr. Marri. Prozac increased. Recommended £'u in 4-5 weeks.
Groups and Individual Counseling: 11116: Individual session. 11115-12/15: Attended groups routinely. 12116-1116: Attended groups routinely. 2/24: Individual session. 2/24-present: Continued to attend groups routinely.
Assessments: Overall, patient received an adequate level of mental health care. Although he was referred to the RTU upon intake into the jail, he was not again seen by psychiatry for approximately 7 weeks. One reco=endation would be to ensure that patients who are re-starting or new to psychotropic medication be seen within a minimum of 4 weeks when at an RTU level of care. Otherwise, patient had a consistent level of follow-up. Some psychiatric notes did not indicate reasons/indications for med changes and targets for the:se medication changes. Some statement about the patient's course of treatment, interval fmdings, and focus of interventions would be helpful in determining their response to treatment.
Patient #4: JB.
Identifying Information: Patient is a 53 y/o M with h/o mood disorder, alcohol use dlo,

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multiple past inpatient psychiatric hospitalizations, suicide attempts (at least once while in custody, in 2013), taking psychotropic medication and incarcerated on 1115/15.
Inten,al History: Patient was referred for MH assessment on intake. He was incarcerated on 1115115 and seen by MH on the following day. He was transferred to 2N at that time due to "risk of decompensation." He was transferred to 2S on 11/9 and transferred to RTU on 11/16.
Psychiatry: 11/7: patient seen by PA (Ms. Balawender) on 2N. He was started on Depakote, Risperdal and Trazodone (meds verified in his property). He was diagnosed with Mood D/o ar1d Alcohol Dependence. 11/8: Seen by PA. Continued on current meds. 1119: Seen by Dr. Paschos. Continued on current medications, Mood NOS vs. SIMD along with alcohol dependence. Not tending to hygiene and isolative. Transferred to 2S for subacute obs/chronic care. 11116: Seen by Dr. Howard on 2S. Discharged to intermediate psych. 1119: Seen by Dr. McNeal on RTU. Continued diagnoses of mood disorder and alcohol dependence. No med changes. F/u in 4 weeks. 2/22: Seen by Dr. McNeal. Reporting AH so increased Risperdal. ROI signed for past psych inpatient. F/u in 4 weeks. 3/23: Seen by Dr. McNeal. Continued present management, status improving. f/u in 4 weeks.
Group and Individual Sessions: 12/16-present: routinely attended group sessions offered. 1130: Individual session. 2/6: Individual session. 2/27: Individual session.
Assessment: Patient received an adequate level of mental health care except for untimely appointments with the psychiatrist related to psychiatrists 'allocation issues. He was seen routinely by psychiatry within the time frame specified in the psychiatry notes. Plan of care was appropriately documented, patient's progression and rationale for medication changes.
Patient #5: P.M Identifying Information: Patient is a 42 y/o M with h/o PTSD, depression and Xanax use disorder, incarcerated on September 26, 2015.
Interval History: Patient was admitted to detox on intake given his reported history of Xanax use (unprescribed). He was designated a P2 and seen by Dr. Ward for medication management. He was seen by MH several times upon request, often asking for new meds or medication changes. On 11124, was referred to P3 level of care for further observation of his reported symptoms and admitted to RTU. He was sent to Stroger 12/5 due to reported symptoms of stroke, but stroke was not confirmed on imaging. Psychiatry and

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neurology believed that patient's tremor and dysarthria was secondary to EPS and Haldol administration. He was transferred back to the jail and the infirmary on 12/9. He was admitted to RTU on 2/2. It appeared he went back to the infirmary from 2/7-3/2. Neurology saw patient in mid-March and noticed bradykinesia and other symptoms. They noted that he had a d/o schizophrenia.
Psychiatry: 10/6: Dr. Ward saw patient as a consult while patient was in detox. Patient reported AH in addition to PTSD symptoms. Dr. Ward diagnosed him with Undifferentiated Schizophrenia and PTSD. She started him on Remeron and Thorazine and recommended :fi'u in 6-8 weeks. 1115: Seen by Dr. Ward. Stated his medication did not work and cannot sleep. Continued to endorse AH. Dr. Ward confirmed dlo schizophrenia. She changed medications to Haldol and Trazodone. F/u for 8-12 weeks. 11124: Seen by Dr. Ward. Increased Haldol and Trazodone due to subjective complaints. Referred to P3 level. 12/7: Seen at Stroger by Dr. Watts as a psychiatric consultation. Dr. Watts noted that patient's presentation was not consistent with psychosis. Dr. Watts reviewed multiple past outpatient notes for patient. He recommended that all antipsychotics be stopped, stopped Trazodone and started Doxepin. His primary diagnoses were PTSD and Alcohol Dependence. Haldol had been stopped while at Stroger due to possible EPS. 12/10: Seen by Dr. Paschos as a consultation after patient returned from Stroger. Medications had been restarted by Dr. Kelner. Patient was restarted on same regimen as he received prior to Stroger transfer-which included Haldol and Trazodone. Patient asked for Doxepin but was not aware he was receiving Trazodone. Benadryl added for sleep, diagnoses were carried over from pre-Stroger evaluation (Schizophrenia, PTSD, Alcohol Abuse). 12/22: Seen by Dr. Paschos as a consultation. Patient continued to c/o insomnia. Dr. Paschos noted recent eval at Stroger and subjective c/o EPS in the past. He did not believe that patient showed signs ofEPS on exam and he increased patient's Haldol. No change in diagnoses. 2/1: Seen by Dr. McNeal. Patient stated that he is drooling and feels sedated. He asked for Haldol to be stopped. Dr. McNeal reviewed patient's course including his stay at Stroger. She noted that patient's symptoms were atypical and his main focus has been sleep. He was not showing objective signs of psychosis. She decreased both Haldol and Trazodone. Carried over diagnoses. He was to return for flu in 2 weeks. 3/22: Seen by Dr. McNeal. Patient complained of potential restless legs. Dr. McNeal noted that his psychotic disorder diagnosis is questionable. She diagnosed him with primary dx as alcohol abuse. She switched him from Haldol to Risperdal and increased Trazodone per patient request.
Group and Individual Sessions: 2/1-/2/6: Only attended a few groups. Refused 3 days in a row. 3/2-4/1: Intermittently attended groups. 3/9: Individual session. 411-present: It appeared that patient intermittently attended groups.

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Assessment: Documentation by Dr. McNeal was very good and noted the patient's course, charts reviewed, and assessment which was integrated into his plan of care. One potential area of improvement was related to diagnosis. It appeared that patients diagnosis and medications were carried over after his Stroger assessment, though neurology and psychiatry at Stroger had raised concern about patient's antipsychotic medication and the need for this given ? of EPS. Would reco=end that for continuity purposes, a patient's notes and discharge su=ary is reviewed and noted in documentation upon return from medical hospitalization. Patient was also seen by a number of different psychiatric providers and it appeared his diagnoses was carried over from mcounter to encounter, though questions remained whether he experienced true psychosis. If patients are unable to be seen by a recurring provider, would reco=end that increased collaboration occur between providers or more detailed thought process in notes so that when the subsequent provider evaluates the patient, he/she may review the chart and be alerted as to the prior provider's concerns and focus of treatment.
P2 Charts and Patient Data
Patient #1: C. C. Identifying Information: Patient is a 42 y/o M with h/o heroin abuse and h/o psychotropic medication while in prison but unclear psychiatric diagnosis, incarcerated onMarch26, 2015.
Interval History: Patient seen by MH for intake on 12/17, unclear source of referral. He reported taking Haldol and Remeron when at the prison and he was referred to psychiatry. He was seen initially by psychiatry on 12/23.
Psychiatry: 12/23: Dr. Advani saw patient. Patient stated he did not want medications and had no issues. Dr. Advani stated he would try to get records from DOC, no meds at that time and RTC in 3 months. Designated as P2. 2/2: Seen by Dr. Ward. Started on Remeron for anxiety. Flu in 8-12 weeks. Diagnoses of Anxiety and Heroin Abuse. 3115: Seen by Dr. Ward. Continued on Remeron. Flu for 8-12 weeks.
Group Sessions: 12/31 : Coping Skills, attended. 1127: Seen in MH clinic by Ms. Thigpen.
Assessment: Patient received an adequate, timely level of mental health services. He saw psychiatry on a routine basis, even more frequently than indicated in the notes.
Patient #2: L. T Identifying Information: Patient is a 55 y/o M with h/o depression and multiple medical problems, incarcerated on October 29,2014.
Interval History:

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 97 of 100 PageID #:5096
Patient initially seen by MH on 12/1115 in response to HSR in which he stated he was depressed. He was referred for supportive counseling and consistently saw MH for sessions in December and the early part of January. He saw psychiatry twice as noted below.
Psychiatry: 1/1116: Seen by Dr. McNeaL She diagnosed him with depression and started Remeron. Flu for 8-12 weeks. Diagnosed with Heroin Abuse and Depressed Mood. 2/9: S<een by Dr. Ward. Remeron renewed. Diagnoses carried over.
Group/Individual Sessions: 12/8, 12117, 12/24, 1/8, Individual Sessions 2/4: Anger Mgt group-attended 3/17: Music therapy-attended.
Assessment: Patient received an adequate level of MH services. He was seen by psychiatry in a routine manner, albeit by different providers. It was unclear if he was to continue with individual sessions, as his therapy notes did not indicate when he was next to follow up.
Patient #3: J.H Identifying Information: Patient is a 38 y/o M with referral to MH due to reported history oftaking psychotropic medication but unclear psychiatric diagnosis. He was incarc,erated on November 11, 2014.
Interval History: Patient seen by MH on 11113114 and was referred to psychiatry. He was first seen by psychiatry on 11/8/14 and has consistently seen psychiatric providers since that time and remained on a P2 leveL
Psychiatry: 11118/14: Seen by PA Ms. Kalman. Diagnosed with schizophrenia and noted that she would restart medications but note does not indicate what meds were started. Noted that patient was to go out on EM that week. 12/9: Seen by Dr. McNeal. Continued Effexor and Thorazine. Continued dlo schizophrenia. 1/2-Seen by PA Kalman. She increased Effexor. 1122: Seen by Dr. Ward. Increased Effexor and started BenadryL RTC in 2 months. 3/2: Seen by Dr. Ward. Noted depressed mood. Stopped Benadryl and started Remeron. Continued Effexor. RTC in 2 months. 6/9: Seen by Dr. Marri. Diagnosed him with depression, continued meds and RTC in 8 weeks. 8/11: Seen by Dr. Marri. Dx of depression and insomnia. Sleep hygiene. RTC 8 weeks. 10/13: Seen by Dr. Ward. Discontinue Effexor and raised Remeron. RTC 6-8 weeks. 11120: Seen by Dr. Ward. Diagnosed with Mood Disorder and Geodon added to Remeron. 1/7: Seen by Dr. Ward. Meds renewed. RTC in 8-12 weeks.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 98 of 100 PageID #:5097
3/9: Seen by Dr. Ward. Increased Geodon. RTC 8-12 weeks. 4/15: Seen by Dr. Ward. No med changes. RTC 8-12 weeks.
Mental Health/Group/Individual Contacts: 11125/14: Seen by MH to discuss SW needs. 11/26: Seen in MH clinic. 12/7: Seen by MH for clearance for seg. 1120: Asked to see psychiatrist about Benadryl. 4/9: Seen for clearance to seg. 7/1: Music therapy-attended 7/3: Community mtg-attended 7/11: Seg clearance. 9/8: Community mtg 9/26: allegedly throwing Effexor in the trash. 10/27: Group 11/17: group 12/2: Group 12/22: Group 2/8: Group 3/7: Anger mgt 3114: Anger mgt 4/4: Anger mgt
Assessment: Patient received an adequate level of care. He received psychiatric services in a timely and routine manner-often seeing a psychiatrist well before the recommended follow up times.
Patient #3: E.S. Identifying Information: Patient is a 41 y/o M with reported hlo psychotic and/or bipolar disorder, incarcerated since January 17, 2015.
Interval History: Patient referred to MH on intake due to his reported history of psychiatric issues. He was reported a hospital takeover but not seen in RCDC. He was deemed safe for Division 6 when in intake but while there he became disorganized and agitated and was transferred to 2N on 1120 or 1/21. He was eventually transferred to 28 and deemed safe for discharge on 2/17 to P3 status. Patient remained in RTU until 10/6 at which point he was deemed appropriate for transition to P2 status.
Psychiiatry: 1/23-2/17/: Dr. Paschos saw patient while he was on 2N. Diagnosed with psychosis and started pm and scheduled Thorazine. Patient seen consistently by psychiatric providers while on 2N and then 28. Medications at discharge were Thorazine pm and Depakote scheduled. 3/31: Dr. Advani saw patient. Obtained Depakote level, started Zyprexa. Continued dlo psychosis.

Case: 1:10-cv-02946 Document #: 333 Filed: 11/14/16 Page 99 of 100 PageID #:5098
4130: Seen by Dr. McNeal. Ongoing AH and anxiety, increased Zyprexa. Flu in 4 weeks. 611: Seen by Dr. McNeal. Added Hydroxyzine. RIC 4 weeks. 712: Seen by Dr. Advani. Increased Zyprexa. 8110: Seen by Dr. McNeal. No changes, consider P2. RIC 4-6 weeks. 9118: Seen by Dr. McNeal. Increased Zyprexa, to check lipids at next apt. Flu 4 weeks. 10128: Seen by Dr. Ward. Started Trazodone. RIC 4-6 weeks. 1/7: Seen by Dr. Ward. Med renewal. RIC 8-12 weeks. 418: Seen by Dr. Ward. Diagnosis of schizophrenia made this visit. Increased Zyprexa.
Group Contacts: Attended groups throughout RTU stay. November 2015: Offered and attended 2 groups December 2015: Offered and attended 1 group February 2016: Offered and attended 1 group April2016: Offered and attended 1 group
Assessment: Patient received an adequate level of mental health care. One psychiatry note recommended flu within 4-6 weeks and patient was next seen in 9 weeks, which would still be within a 3 month time frame.
Patient #4: M.U.
Identifying Information: Patient is a 43 ylo F with hlo opioid dependence and anxiety with h/o outpatient psychiatric treatment, incarcerated on November 15,2015.
Interval History: Upon intake into the jail, the patient was referred to outpatient psychiatry. It appeared she left the jail and returned on 1130. She was seen by MH again on 113 0 for intake and referred to psychiatry given hio recent heroin use and reported anxie~y symptoms. Designated a P2.
Psychiatry: 2117: Seen by Dr. Advani. Diagnoses of Benzo Dependence, Opioid Dependence and Adjustment Dlo. Started Zoloft and Trazodone. RIC 8-12 weeks. 4111: Seen by Dr. Menezes. Stopped Trazoclone clue to headache. Increased Zoloft and added Remeron. Diagnosis unchanged.
Group Contact: February: 2016: Offered and attended 3 groups. March 2016: Offered and attended 4 groups. April2016: Offered and attended 1 group.
Assessment: This patient was receiving an appropriate level of mental health care.
Summary of Observations:
Frequency of Psychiatry Visits:

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With few exceptions, patients were seen within the reco=ended timeframe (maximum of every four weeks while in RTU and maximum of every three months as P2s). Some notes did not indicate a reco=ended time to return to clinic so this metric was difficult to track. However, psychiatric follow-up for inmates transferred from the PSCU to the RTU was not timely.
Consiistency/Continuity of Plan of Care: The plan and assessment aspect of documentation was variable. Some clinicians were specific in their targets of intervention and indications for medication changes while other notes made no or limited mention of rationale for therapies. With one patient, it appeared that hospital notes (upon return) were not reviewed or at least incorporated into the plan of care, at least not within a timely manner. Several patients had a myriad of providers throughout their course, but this usually appeared to be a function of location (i.e., moved between units or different levels of care) rather than a function ofprovider availability.
Diaglllosis: Diagnoses largely remained unchanged from visit to visit and were carried over when seen by a new provider. The diagnoses remained consistent. When a patient was seen by a new provider, it often was unclear whether the new provider had reviewed the chart and/or done a new, independent assessment ofthe patient in order to arrive at their diagnosis and plan.

 
 Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 1 of 110 PageID #:5131

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

UNITED STATES OF AMERICA,

Plaintiff,

v.

COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD P'RESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),

No.lO C 2946 Judge Virginia Kendall

Defendants,

Monitor Jeffrey L. Metzner, M.D.'s Final Report December 11, 2016

Jeffrey L. Metzner, M.D., P.C. 3300 East First Avenue Suite 590 Denver, CO E-mail: Jeffrey.metzner@ucdenver.edu

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 2 of 110 PageID #:5132

JEFFREY L. METZNER, M.D" P.C. 3300 EAST FIRST AVENUE SUITE 590 DENVER, COLORADO
TELEPHONE (303) 355-6842 FACSIMILE (303) 322-2155

MEMORANDUM

TO:
FROM: DATE: RE:

Donald J. Pechous, Esq. Cook County State's Attorney's Office 500 Richard J. Daley Center Chicago, illinois 60610
Paul O'Grady, Esq. Peterson Johnson& Murray 233 South Wacker, 84th Floor Chicago, Illinois 60606
Kerry Dean, Esq. U.S. Department of Justice P.O. Box 66400 Washington, DC 20035-6400
Jeffrey L. Metzner, M.D. December 11, 2016 US.A. v Cook County, eta! No. 10C2946

I have completed my assessment of the mental health services offered at the Cook County Department ofCorrections (CCDOC) through Cermak Health Services ofCook County (CHSCC). I site visited CCDOC from November14-18, 2016.
Sources ofinformation utilized in compiling this report included the following:
1. review of documents provided in response to my written request for pre-site information, which included the following documents: a. status update to the Agreed Order, b. Mental Health Quality Improvement Committee meeting minutes, c. Suicide Prevention Committee meeting minutes, d. numerous mental healthcare quality improvement studies,
2. interviews with many inmates in group settings in Division 8 (RTU and the Cermak units) and Division 2,
3. observation of treatment activities in Division 8,

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 2 of13
4. information obtained from key administrative and clinical staffthat included, but was not limited to, the following persons:
' f
a. Jay Shannon, M.D. (CEO, Cook County Health and Hospitals System), b. Linda Follenweider, R.N., N.P. (Acting Chief Operating Officer Hospital Based
Services), c. Connie Mennella, M.D. (Chair, Department of Correctional Health Services), d. Nneka Jones, Psy.D. (First Assistant Executive Director), e. Kenya Key, Psy.D. (Chief of Psychology), £ David Kelner, M.D. (Chief of Psychiatry).
As always, I found the stafffrom CHSCC and CCDOC to be courteous and helpful throughout my five-day site visit.
In this report the term "inmate" will be used in contrast to "detainee" in order to be consistent with the Agreed Order's terminology, although the vast majority of persons admitted to CCDOC are pre-trial detainees.
Overview
The Cook County Department of Corrections consists of 9 main divisions in a group ofbui1dings covering over 100 acres. The inmate count during November 15,2016 was 8,029
Reference should be made to Appendix I for a more detailed summary of population and capacity information.
Findings
As per the June 3, 2010 memorandum regarding the June 2, 2010 meeting that included attorneys from the Department of Justice, attorneys and representatives ofthe Defendants, and the monitors, my findings relevant to the Mental Health Care section of the Agreed Order are summarized in Appendix IV (5-13-1 0 Agreed Order Mental Health provisions). Appendix IV includes excerpts from prior site assessment reports ifthey provide relevant contextual information. Consistent with the June 2, 2010 meeting, I have forwarded my input to the other monitors who have primary responsibility for sections that overlap with various mental health provisions as summarized in the June 3, 2010 memorandum.
Appendix II summarizes the seventeen mental health provisions of the Agreed Order that have been in substantial compliance for at least 18 months. My assessment during this site visit did not raise any concerns that these provisions were no longer in substantial compliance. Appendix III summarizes mental health provisions of the Agreed Order monitored by other monitors.
The psychiatric vacancies were all filled during August 2018 via full-time employees, part-time employees and contract employees. Attachment B provides a summary of the current staffing

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USA v Cook County, et al.
Page 3 ofl3
allocations and vacancy rate. Information Requests Appendix V summarizes my revised document request for my next site assessment scheduled for April10-14, 2017. Please do not hesitate to contact me if I can answer any further questions. Sincerely,
Jeffrey L. Metzner, M.D.

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Executive Summary-Thirteenth Monitoring Report (Mental Health Provisions)
Since the November 2016 site visit, the most significant progress has occurred in the following seven areas:
1. Since August 2016, there been no functional vacant psychiatrists' positions.
2. Compliance has been achieved re: meeting timeframes by psychiatrists in response to emergent, urgent and routine referrals.
3. Compliance has been achieved with the provisions of the Agreed Order regarding infirmary psychiatric care.
4. Continued improvement in the mental health programming (both in quantity and quality) for inmates in the RTU.
5. Continued implementation of the Intensive Management Unit (IMU) in the RTU.
6. Continued improvement in the quality improvement process, which remains in substantial compliance.
7. An additional14.0 FTE mental health specialists' positions have been funded.
CCDOC has continued to implement a plan for increased out of cell time for all inmates in segregation units as part of the CCDOC plan to gradually increase the recreational time for segregation inmates to at least three hours per day. In addition, the custody staff is providing increased correctional programming on a weekly basis to inmates who are willing to participate.
The leadership ofKenya Key (ChiefPsychologist, Ph.D.), David Kelner, M.D. (ChiefPsychiatrist) and Carlos Gomez, Psy.D., Linda Follenweider, R.N., N.P (Acting Chief Operating Officer Hospital Based Services), and Connie Mennella, M.D. is impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is good.
An additional four provisions have now been in compliance for at least 18 months, which means a total of 16 provisions have been in compliance for at least 18 months.
Three (3) provision previously in partial compliance are now in substantial compliance, which means there are now four (4) provisions that have substantial compliance for less than 18 months.
A total of five (5) provisions remain in partial compliance, although three of these provisions are essentially related to staffing vacancies and/or allocation funding issues. Mental health leadership will be worlr..ing with me to complete a staffing needs analysis by January 1, 2017.
The main obstacle related to the provisions in partial compliance center on the following issues:
1. Mental health staff vacancies and/or allocation issues, which impact both the RTU and

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page2 of8
outpatient levels ofmental healthcare services. 2. The need for increased structured therapeutic time for RTU inmates as well as
unstructured time in the recreational areas. 3. The current lack of adequate mental health programing for SMU RTU segregation
inmates. 4. The current lack of adequate mental health programming for protective custody RTU
inmates.
CCDOC and Cermak leadership staff are actively addressing the above obstacles.
Summary of Compliance Findings
The following provisions were assessed to be in substantial compliance (with the initial date of substantial compliance noted in parenthesis):
Bolded provisions indicate that the provisions have been in substantial compliance for more than 18 months.
59. Assessment and Treatment
a. Results of mental health intake screenings (see proVIsion 45.c, "Intake Screening") will be reviewed by Qualified Mental Health Stafffor appropriate disposition. (6/12)
b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates' mental health needs. Said policies shall include dellnitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs. (10/12)
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staffwith appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-N-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and review available information regarding any diagnosis made by the inmate's community or hospital treatment
2

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 3 of8

provider, and shall account for the inmate's psychiatric history as a part of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record. (11116)

f.

Cermak shall provide 24-hour/7-daypsychiatric coverage to meet inmates' serious

mental health needs and ensure that psychiatrists see inmates in a timely manner.

(11116)

h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate. (11116)

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with a mental health caseload roster listing the inmates

currently receiving mental health care. (6/12)

J. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status. (10/12)

k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
L Cermak shall ensure that 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 or by Qualified Mental Health Staff with
, appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified

3

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page4 of8
Mental Health Professional, or Qualifiied Mental Health Staff with appropriate, on-site supervision by a Qualifiied Mental Health Professional. (11/15)
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year. (6/12)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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. (4116)
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. 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;
4

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 5 of8

(5) observation; (6) intervention; and (7) mortality and morbidity review. (11/13)

62. Suicide Precautions a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks. b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks. c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff. d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances. (11/15)

63.

Cermak shall ensure that Qualified Mental Health Staff assess and interact

with (not just observe) inmates on Suicide Precautions, and document the

assessment and interaction on a daily basis. (11/10)

64. Suticide Risk Assessments a. Cermak 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.
b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level oflethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record. (11/13)

5

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 6 of8

65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been ]performed and approved by a Qualified Merntal Health Professional, in consultation with a psychiatrist. A Qualified Mental Hlealth Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. (11/15)

66. Suicide Prevention Policies

a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with
CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards. (6/12)

67.

DFM shall ensure that cells designated by CCDOC or Cermak for housing

suicidal inmates shall be retrofitted to render them suicide-resistant (e.g.,

elimination of protrusive shower heads, unshielded lighting or electrical

sockets). Inmates known to be suicidal shall not be housed in cells with

exposed bars. (6/12)

68. Suicide Prevention Training

a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools. (12/1 0)

6

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Executive Summary Tenth Monitoring Report (Mental Health Provisions) Page 7 of8
70. Cermak shall document inmate suicide attempts at the Facility, as def"med by the Suicide Prevention Committee's policies and procedure in accordance with generally accepted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agnement. (6/12)
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant. (11115)
The complete list ofprovisions that were in partial compliance is as follows:
59. Assessment and Treatment
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
e. Cermak shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the inmates' diagnoses.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defining the various levels of care and identifYing the space, staffing, and programming that are appropriate to each identified level of care.
7

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o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
60. Psychotherapeutic Medication Administration a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record. b. Cermak shall ensure timely implementation ofphysician orders for medication and laboratory tests. Cermak shall ensure that 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.
8

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USA v Cook County, et a!.
Page4 of13
Appendix I

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ICDDK COUNTY SHERIFF•& OFFICE
.BUREAU DF ANALYTIC& AN!D RESEARCH
DUII!JINIIBB INTELUGIIII!Nalii UNIT

Sheriffs Daily Report

11/15/2016

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Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 16 of 110 PageID #:5146
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Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 17 of 110 PageID #:5147 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 5 of13
Appendix II

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 18 of 110 PageID #:5148

59. Assessment and Treatment

a. Results of mental health intake screenings (see proVIsiOn 45.c, "Intake Screening") will be reviewed by Qualified Mental Health Staff for appropriate disposition.

Compliance Assessment: Substantial compliance (since June 2012).

Factual Findings:

May 2014 Metzner assessment: Little change from November 2013. Still concerned re: likely false positive screening numbers.

November 2014 Cermak Status Update

From intake referrals by nursing persounel (female intake= RN; male intake= RN or other nursing designees) conducting screening upon all incoming inmates in RCDC, to the secondary mental !itealth assessments, the following referral numbers represent the percentage of referrals to mental health by month from May 2014 through September 2014, which show that the male intake and secondary mental health referrals are remaining essentially constant at this point, while there is a marked increase in female referrals to secondary mental health assessment. Further investigation by the way of a QI study of the Initial Intake Evaluation will need to be conducted.

SECONDARY MENTAL HEALTH REFERRALS GENERATED BY INTAKE NURSING:

Male % Referral

Total Female% Referral

Total

May_2014 23.37%

832 3560 May_2014 57.08%

246 431

Jun 2014 22.41%

762 3401 Jun 2014 64.30%

272 423

Jul 2014 24.82%

865 3485 Jul 2014 63.79%

273 428

Aug_2014 22.48%

918 4083 Aug_2014 65.46%

290 443

Sep_2014 22.17%

774 3491 Sep_2014 79.42%

274 345

The chart below looks at the data from all new admissions to the mental health caseload, by month and gender. The charts reflect those inmates identified and classified as P-2, P-3, or P-4 during the secondary mental health assessment at intake or within the three days following admission versus those who were placed on the mental health caseload at some later point during incarceration. The inter-rater reliability study has not yet been conducted for the Mental Health Specialists within RCDC due to staffing levels and other competing priorities. The data reflects continual improvements in identifYing mentally ill inmates at the onset of incarceration.

MENTAL HEALTH CASELOAD GENERATED BY INTAKE V. DURING

INCARCERATION:

Admit Month Male

Mental Health Classification within 3 day after Admit Mental Health Classification

During Lncarceration

9 2014

95.28%

4.72%

8 2014

92.32%

7.68%

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 19 of 110 PageID #:5149

7 2014

90.12%

9.88%

6 2014

89.37%

10.63%

5 2014

87.22%

12.78%

Admit Month Female

M,ental Health Classification within 3 day after Admit

During fucarceration

9 2014

93.68%

6.32%

8_2014

88.09%

11.91%

7_2014

83.73%

16.27%

6 2014

87.20%

12.80%

5 2014

81.95%

18.05%

Mental Health Classification

November 2014 Metzner assessment: Substantial compliance remains.

b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates' mental health needs. Said policies shall include delmitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs.

Assessment: Substantial compliance (since October 2012)

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with a mental health caseload roster listing the inmates

currently receiving mental health care.

Assessment: Substantial compliance (since June 2012)

Factual Findings:

October 2012 Cermak Status Update

• <;;emer is now able to generate a patient roster for the mental health caseload to provide to the CCDOC; however, it does not yet include the level of care/mental health classification as this is being built within the alert system.

November 2013 Metzner assessment: Substantial compliance continues.

November 2014 Cermak Status Updates

Cemer and CCOMS now have a fully operational, direct interface which makes mental health classification/level ofcare immediately and accurately available to CCDOC by midnight each day.
November 2014 Metzner assessment: No change

j. 'Vhen CCDOC alerts Cermak that an inmate is placed in lock down status for dlisciplinary reasons, a Qualified Mental Health Professional will review the

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 20 of 110 PageID #:5150
disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status.
Assessment: Substantial compliance continues (since October 2012).
Factual Findings:
November 2015 Metzner assessment: Substantial compliance continues
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
. , I. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:
November 2016 Cermak Status Update
CCDOC Administration brought in the State of IL statutory compliance their disciplinary SMU process and, presently, detainees' stay in disciplinary SMU cannot exceed 29 days, whereupon,

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 21 of 110 PageID #:5151
they are removed from SMU and undergo additional review in order to determine whether they need to be put back in segregated setting. Mental Health Department continues to provide 24 hour SMU screening for this cohort of detainees reentering restrictive settings. Mental health staff continues to conduct rounds on restrictive housing units at nllnimum weekly (in addition to the rounds conducted by Nursing/PCS). New updated universal SMU placement notification sheet has been created and implemented. Detainees moving from one segregation tier to another are not in need of additional screening, however are documented on the notification sheet for institutional purposes. Mental health, unable to differentiate between those who were in need of a screen from those who are not, count the compliance rates at face value. Please refer back to Div. IX updtaes for discussion. Please see PDF Appendix for SMU Screening Compliance data.
To centralize the notification to C=ak mental health and nursing staff of detainees placed in Special Management Units, both agencies agreed upon a revised process that mimics the successful bed control notification process. Cermak leadership will be creating an SMU Notification email address that will be used by the DOC Classification unit to provide daily notifications.
November 2016 Metzner assessment: Substantial compliance continues
m. Cermak shall maintain an updated log ofinmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive medication. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings:
June 2012 Metzner assessment: In addition to the above update section, staff demonstrated a capacity to also include dosages of the psychotropic medications in the required log.
October 2012 Cermak Status Update
• The mental health roster has been updated. The roster is being updated routinely. Any inmate on the roster who is identified as missing an ICD 9 code as the result of data entry of a free text or another issue in Cerner is subsequently referred to a psychiatrist for entry of a diagnosis and problem in correspondence to any prescription of a psychotropic medication.
November 2014 Metzner assessment: No change.

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61. Suicide Prevention Policy a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. 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.
Compliance Assessment: Substantial compliance (11113)
Factual Findings:
November 2013 Metzner Assessment: Significant improvement is noted in the Mortality & Morbidity Review reports, which are now using a root cause analysis format.
As described elsewhere in this report, problems remain relevant to the intake screening/assessment process, especially in the context of priority referrals and segregation admissions screening. These issues are addressed elsewhere in this report.
November 2015 Metzner assessment: My April2015 reco=endations were implemented. Substantial compliance continues.
62. Suicide Precautions
a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 23 of 110 PageID #:5153
jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks. c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff. d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
Complliance Assessment: Substantial compliance (11115)
Factual Findings:
April2016 Metzner assessment: Substantial compliance continues
November 2016 Cermak Status Update
See PDF Appendix for Suicide Detection and Prevention QI Report Qtr. 1-3 2016
November 2016 Metzner assessment: Results of the above referenced QI report were consistent with continued compliance.
63. Cermak shall ensure that Qualified Mental Health Staff assess and interact with (not just observe) inmates on Suicide Precautions, and document the assessment and interaction on a daily basis.
Compliance Assessment: Substantial compliance (since November 2010)
Factual Findings:
November 2013 Metzner Assessment: The EMRs of 10 inmates on suicide observation status were reviewed. Documentation was present in the EMR that mental health staff interacted with (not just observed) these inmates on Suicide Precautions and documented their assessment and interaction on a daily basis with one exception. A patient on 2N while on suicide precautions only received nursing notes one day, 10/20/13, which was a Sunday. There were no mental health assessment notes documented that day. November 2014 Metzner assessment: No change.
64. Slllicide Risk Assessments
a. Cermak shall ensure that any inmate showing signs and symptoms of suicide

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 24 of 110 PageID #:5154
'
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. Cermak shall ensure that the risk assessment shall include the following: (1) description ofthe antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level oflethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record. (11/13)
65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:
November 2016 Cermak Status Update
Please refer to QI reports referenced in provision #62.
November 2016 Metzner assessment: Review of the relevant QI results were consistent with the presence of continued substantial compliance.
66. Suicide Prevention Policies
a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision ofinmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings:

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 25 of 110 PageID #:5155
November 2014 Metzner assessment: No change
67. DFM shall ensnre that cells designated by CCDOC or Cermak for housing suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings: October 2012 Cermak Status Update:
• Iru:nates known to be suicidal are not housed in cells with exposed bars; rather, they are uansported under 1:1 observation by a CO to Cermak and placed into a suicide resistant cell, as ordered by a psychiatrist, when deemed to be a suicide risk, and placed on close or constant observation, as ordered in Cerner.
November 2014 Metzner assessment: No change.
68. Suicide Prevention Training
a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following 1topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools.
Compliance Assessment: Substantial compliance (since December 2010)
Factual Findings:

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 26 of 110 PageID #:5156
April2013 Metzner assessment: Relevant training continues to be provided to staffby the mental health staff.
November 2013 Metzner assessment: No change.
May 2014 Cermak Status Update
DOC Advanced Mental Health Training for In-Service: The DOC has now initiated its second of many scheduled two-week in-service training courses for existing DOC tenured Correctional Officers in Advanced Mental Health Training to include Crisis Intervention Training (CIT) and Cermak Health Services participates in the CIT component through a Correctional Psychologist who describes the Cermak mental health delivery system and the mental health classification procedure as welL This program is provided at the jail on-site in training facilities within the compound although it is from the Academy curriculum.
Cermak Suicide Prevention Training: The Cermak mental health training in Suicide Prevention for mental health, nursing and medical professionals is ongoing and is offered routinely to ensure that all staff maintain their current status in suicide training according to policy requirements. A Correctional Psychologist provides this training at least twice annually to assure ongoing adherence to requirements in training and also offers Restraint Training as welL
November 2014 Cermak Status Updates
Same as above, training continues for all disciplines as described in May 2014 Cermak Status Update.
November 2014 Metzner assessment: No change
70. Cermak shall document inmate suicide attempts at the Facility, as dermed by the Suicide Prevention Committee's policies and procedure in accordance with generally accepted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.
Compliance Assessment: Substantial compliance (since June 2012)
Factual Findings:
October 2012 Cermak Status Update: • All inmate serious suicide attempts are monitored and reported at the Suicide Prevention Committee that occurs on the fourth Friday of each month in Cermak, conducted by the Chief Psychologist, with an agenda and minutes maintained. A detailed report of each serious suicide is completed and reviewed by a Correctional Psychologist at the committee

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 27 of 110 PageID #:5157
meeting following the attempt and it is treated as a morbidity review for the learning experience. CCDOC incident reports and Cermak medical records as well as court reports are included in the morbidity review. Serious suicide attempts are also reported to the monthly overall CQI committee and to the Sheriff's Office. Any serious suicide attempt also receives an alert in Cemer and in IMACS which is now also passed on to the Courts so that they are aware of any history as well. There had been two instances of serious attempts in court, where the court was not aware of prior attempts. As a result, the Court now participates in the monthly suicide prevention meeting and is now aware ofthese alerts in Cerner and IMACS, a notable improvement directly attributable to a serious suicide attempt.
October 2012 Metzner assessment: Substantial compliance continues.
May 2014 Cermak Status Update:
Suicide P'reventiou Committee Review: The Suicide Prevention Committee attempts to meet on the fourth Friday each month and the agenda has a standing item to review any and all serious suicide attempts for patterns that could identify areas for improvement to prevent future occurreQ;9es from repeating events. Meeting minutes reflect review of individual cases and ongoing efforts to prevent recurrence by efforts to correct any deficiencies identified. DOC, Cermak, the Sheriff's Office and the Court Officials all participate in this multi-disciplinary meeting.
November 2014 Cermak Status Updates
Suicide Prevention Committee Review: The Suicide Prevention Committee attempts to meet on the fourth Friday each month and the agenda has a standing item to review any and all serious suicide attempts for patterns that could identify areas for improvement to prevent future occurrences from repeating events. Meeting minutes reflect review of individual cases and ongoing effbrts to prevent recurrence by efforts to correct any deficiencies identified. DOC, Cermak, the Sheriff's Office and the Court Officials all participate in this multi-disciplinary meeting. Full Root Cause Analyses are completed during these meetings for any completed suicides occurring in the 30 days prior. Root Cause Analyses are also used for other sentinel events as determined by administration. RCAs for two completed suicides since last site visit provided as password protected files under separate cover.
November 2014 Metzner assessment: Substantial compliance continues
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to
;,c assure compliance with each of the provisions of this Agreed Order applicable to

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 28 of 110 PageID #:5158
!that Defendant.
b. Defendants shall each develop and implement policies to address and correct deficiencies that are uncovered during fue course of quality management activities, including monitoring corrective actions over time to ensure sustained resolution, for each of the provisions of fuis Agreed Order applicable to fuat
'" Defendant.
Compllialllce Assessment: Substantial compliance (11/15)
Factual Findings:
November 2016 Cermak Status Update
Several additional QI projects have been undertaken since the last site visit, referenced throughout !this report and/or found in the PDF Appendix.
Mental Health Disposition at Intake Psychiatric Diagnoses, Self-Injury, and Disciplinary Status of"High Disruption" Detainees Disciplinary Beds in Segregation & Self-Injury C=ak Dayroom Hours HSRF Reason for Delay/Not Seen
November 2016 assessment: The pre-site information packet, which included the QI appendix, was well done and extremely helpful. The QI studies were methodologically sound, well written and very relevant. Substantial compliance continues.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 29 of 110 PageID #:5159 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 6 of13
Appendix III

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 30 of 110 PageID #:5160
Appendix ill
Mental health provisions of the Agreed Order monitored by other monitors
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
Complianc'e Assessment: Refer to the report by Dr. Shansky (initially found to be in substantial compliance during 2011 and again during 2013)
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily available, safely secured, suicide cut-down tools.
Compliance Assessment: Refer to the report by Susan McCampbell.
r

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 31 of 110 PageID #:5161 Re: Mental Health Services at CCDOC USA v Cook County, eta!. Page 7 of13
Appendix IV

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 32 of 110 PageID #:5162
Appendix I\1 The Agreed Order Status Update Page 1 of 55

AGREED ORDER

D. MENTALHEALTHCARE

59. Assessment and Treatment

c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, fmds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record.
Compliance Assessment: Compliance (11116)

Factual Findings:

November 2016 Cermak Status Update

October 2016

Total Jail Population as of 10113/2016: 8,226

P2-0utpatient Mental Health

1711 20.7% (of total)

P3-lntermediate Mental Health 436 5.3% (of total)

P4-Psych. Special Care Units

86 1.05% (of total)

Mental Case Caseload

2,233 (27.14%)

76.62%9(ofMH load) 19.5% (ofMH load) 3.85% (ofMH load)

March2016

Total Jail Population as of04/0l/2016: 8,096

P2-0utpatient Mental Health

1550 19.14% (of total)

P3-lntermediate Mental Health 394 4.8% (of total)

P4- Infirmary Mental Health

65 0.8% (of total)

77.15% (ofMH load) 19.61% (ofMH load) 3.23% (ofMH load)

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 33 of 110 PageID #:5163

Appendix I\1 The Agreed Order Status Update Page 2 of 55

Mental Health Caseload

2,009 (24.81%)

The number of patients on Mental Health Caseload has remained relatively stable. Furthermore, the proportion of detainees in Intermediate Level of Care and Outpatient Level of Care- P3 and P2, respectively, has remained constant. Various diversion programs at CCDOC has not diminished the proportion ofthe seriously mentally ill and the violent offenders.

All Providers, Psychologists, MSW and MRS continue to use their personalized access to the Jail Data Link database allowing them to source data about previous admissions to municipal and state institutions receiving federal grants or directly administered by the State ofiL. All Providers, Psychologists, MSW and MRS have personalized access to the Jail Management System (CCOMS) allowing them to review charges, legal and disciplinary history in real time. All the WYSE terminals and desktops that Cermak utilizes across the compound (including RCDC) permit CCOMS access. Mental health staff are routinely seeking releases of information for community providers during the intake process and post intake when needed. Results of the yield in recent month can be found below:

Treatment Records from Community Providers

Cermak has been requesting records from community providers, primarily from Intake/RCDC. In June 2016, a system-wide employment displacement took place that resulted in Cermak losing the Health Information Management Department staffer that was coordinating this process. It took several months to identify a new individual to take on this process and to catch up with the back log. Data for October 2016 was used to conduct a review of this process as the data for this month was the most complete and accurate.

Once an ROI is executed, it is forwarded to Dr. Gomez for review to ensure all fields are completed and that it is valid. Dr. Gomez then forwards the requests to the coordinator who logs the ROI in an Excel database and sends the ROI to the community provider. All records are send back to the coordinator. Upon receipt, the coordinator logs the return date in the same Excel database and forwards the records to the MH department administrative staff. The mental health department administrative staff determine whether the pt is still in custody and forwards the records for those in custody to the requester or the supervising psychologist of the Housing Unit where the patient is currently housed. Upon receipt, the requester enters a brief summary of the records into Cemer, shares the information with the clinical team-including the psychiatristand forwards relevant records to HIMD for scanning into Cerner. Reviewed medical records are scanned to the initial date of admission to CCDOC. If a patient is no longer in custody, the records are forwarded to Dr. Gomez who then includes the summary in Cerner and forwards relevant records to HIMD for scanning into Cerner.

In October 2016, 173 requests were sent out for behavioral health records to community providers. As of 1112116, 83 (48%) of the records had been received within an average turnaround time of7.3 calendar days. The 90 records that have not been received have been

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Appendix IV The Agreed Order Status Update Page 3 of 55

outstanding for an average of 17.3 days. The coordinator contacts all providers who have not sent records within 20 calendar days. A review of the agencies that have not returned records revealed only that these agencies are very diverse but almost all of them are private hospitals or clinics.

As of October 2016 all MH Department employees completed the review of all armually reviewed/updated policies.

Cermak met with DOC Leadership and representatives ofNorthwestem Memorial Hospital to discuss the introduction of Computerized Adaptive Testing (CAT) in RCDC (Intake). Presently, Cermak's role is still being defined. Further meetings between CCHHS Institutional Review Board and Northwestern are pending. Issues ofinterface and compatibility between the research project and already existing Intake flow are to be discussed. CAT has less proven results in terms of detecting several important domains of psychopathology such as psychotic disorders and addictive disorders. It is understood that the Northwestern project will not replace already existing validated process in RCDC.

On average more than 40% of female detainees and approximately 24% of male detainees are referred for secondary mental health assessment from the initial health screening. Additionally, appropriate identification ofmental illness and placement on the mental health caseload at intake remains ,yonsistently over 90%. Please see Excel Appendix for Intake Referral data.

Dr. Gomez continues acting as the clinical supervisor in the RCDC area. During RCDC group supervisions case conferences, including peer review, are conducted to address the quality of secondary mental health assessments and identify outliers among staff. The main focus is to discuss quality of dispositions and risk assessments. Dr. Gomez conducted an ongoing audit and analysis of assessments and dispositions made by the Intake QMHP staff, find excerpts below. The full RCDC QI report can be found in the PDF Appendix.

The table and figure below reflect the disposition made by the QMHP based on the results of a comprehensive mental health assessment for both the spring and sunnner samples. At first glance, the data suggests two significant shifts, a marked decrease in the number of referrals to the intake psychiatrist and a subsequent increase in the number of individuals dispositioned to every level of care. However, these changes may be due the way that mental health staff document their disposition. Based on conversations with the QMHPs affected, they currently document their clinical impressions and anticipated disposition even when they referred to the intake psychiatrist-whereas in the past the staffwould simply document a referral to the intake psychiatrist without noting their recommended level of care. The decision of the intake psychiatrist during the spring period was not captured in the data set. If that data were available, it is suspected that it would look very similar to the summer 2016 disposition pattern.

Table- Disposition Spring 2016

Summer2016

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Appendix IV The Agreed Order Status Update Page4 of 55

DISPOSITION BONDED OUT

RELEASED

REFUSED

MISSING

GP

P2

P3

'·-~

P4 INTAKE PSYCH

COUNT
3 1 9 26 911 1048 279 108
552

TOTAL 2937

PERCENT
0.1% 0.0% 0.3% 0.9% 31.0% 35.7% 9.5% 3.7%
18.8%

COUNT 0
0 0 15 353 492 166 101 30

PERCENT2 0%
0% 0% 1% 31% 43% 14% 9% 3%

100%

1157

100%

Psychiatry face to face visits reflected a steady trend in the second and third quarters of 2016.

A~
1,3

May 1,049

June I
1,143 1

July II 1,o8o 1

I August I September

1,11711

1,1481

Dr. Kelner reviewed psychiatry referrals originating in the intake process as per below (also see Excel Appendix for data): Psychiatry Intake Referrals:

Order I Priority I Status
Month
2016 9 2016 8 2016,7 I 2016 6 I 2016 5 I 2016 4 I 2016 3

I II
#

Seen %

165
186 172 I 165 I I 191 I
ltffi:j
1 210

97.06% 98.41% 97.18% 90.66% 97.45% 94.25% 93.33%

Emergency

I 2) Over4hrs

#

%

2

1.18%

1

0.53%

3

1.69%

13 7.14%

4

2.04%

11 4.87%

10 4.44%

Not Seen

I 4)No Note

#

%

3

1.76%

2 1.06%

2 1.13%

4 2.20%

1 0.51%

2 0.88%

5 2.22%

I #
5
[I] [I]
Cilll
5
13
15

%
2.94% 1.59% 2.82% 9.34% 2.55% 5.75% 6.67%

Total
170 I 189 I 177 I 182 196 226 I 225 I

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AppendixN The Agreed Order Status Update Page 5 o.Ji55

In September 2016 97.6% detainees were seen within 4 honrs (in keeping with the timeframe) when referred with Psychiatry Emergent Referral. Out of the 2.94% that were not seen timely, 1.18% were still seen in RCDC (Intake) but outside of the 4 honr timeframe. 1.76% were not seen in Intake, as they were either fast tracked, given acuity, prior to Psychiatrists being able to see them, to PSCU and MSCU/detoxification nuits. Additionally, a small proportion of that cohort had orders for Psychiatry Intake placed in EMR when it was assumed by MHS that Psychiatry would be present on site, but then, due to call offs Psychiatrists did not show up and original ord·ers were not cancelled.

Urgent(P4)
9 2016 8 2016 7 2016 6 2016 5 2016 4 2016 3 2016

1) Within 24 hrs

93

94.%

98

95.%

100

89.%

100

94.%

93

92.%

112

92.%

I 97 II

90.%

2) Over 24 hrs

4

4.%

No Note

D

2.%

2 EfBCL11 3.%

II 10 I

2

2.%

5 I

5.%

I I

1.%

8 I
10 I

8.% 8.%

B

8

7.%

3

3.%

Total
99 II 103 I
112 I 101 122 108

In September 2016 94% of detainees referred for Urgent Psychiatry Referral were seen within 24 hours (in keeping with the timeframe). The 4% of detainees that were not seen within the next 24 honrs were mostly detainees admitted on Fridays and weekend Psychiatrists saw them later in the day and .detainees who were assigned P4level (were "slated" for PSCU admission) and then were diverted to MSCU and detoxification Units, thus delaying their contact with Psychiatry. The identification ofP4s that are admitted from Intake to locations other than PSCU has been improved following an introduction of Daily PSCU Mental Health Level of Care Tracker which allows Providers review lists of patients with P-alerts in MSCU and see when notes are due. The tracker assists in identification of detainees requiring Psychiatry Consults ordered by Medical Providers in MSCU. Conversely, the tracker enables Medical Providers to identifY and track detainees in PSCU who are in need ofmedical evaluations and follow up. The remaining detainees who did not have any notes written within the required timeframe were transferred to John Stroger Hospital due to medical problems and detox and could not be seen within 24 honrs by Cermak Psychiatrists. There is a system of notifications between JSH Consultation and Liaison Psychiatrists and Cermak Providers to alert JSH CIL Service to their arrival. Furthermore, JSH belongs to/shares the same EMR so there is full access to Cermak's notes at JSH.

Routine(P2/P3)
9 2016

1) Within 14 days
356l 58.%

2) Between 15-21 days

3) Between 22-30 days

19lr 3.% 6 l r 1.%

4) D/C within 15 days
1 162 26.%

5) D/C over 15 days without
Note
9 II 1.%

6) No Note
162 1o.%

Total 614

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Appendix IV" The Agreed Order Status Update Page 6 of 55

8 2016

34 57.% 28 5.% 17

7 2016

3

56.% 31 5.% 4

6 2016 5 2016

3

I 53.% ~II 5.% 12

I 399 59.% I 17 I 3.% 19

4_2016

425 65.% 14 2.% 8

~ I 3_2016
Reason forNo. Note(6)

.... 71.% 0 1 3.%

4

.

SPIDOC/EM/SPFFffiischarge/extradition

Scheduling Issue

False Posi.tive/Seen within Range Cancelled by MH Staff

No Show!'

No Note

PT not on Case Load/No P level

Movement/Lock Down

Duplicate entry

Grand Total

I I I I 3.% 169 1 28·% 21

3.% 1~1 4.%

602

I IDD 1.% 184 32.% 21

4.%

3.% 583

2.%

183 28.% 48

7.%

28 4.%

645

3.% 175 26.% 43

6.%

~ 25 4.%

I I I I 1.%

167 25.% 24

4.%

17 3.% I~

1.% 142 1 2 1.%1~1 3.% 1[11]~ 687

. Co.unt > < ·· · Accunmlatfon

29

46.03%

12

65.08%

7

76.19%

4

82.54%

4

88.89%

3

93.65%

2

96.83%

1

98.41%

1

100.00%

63

100.00%

Chart

35

-8 "

30 25 20 15

10

5

0

SPIDOC

False

/EM/S Schedu Postive Can cell

PFF/Di

ed by No

scharg

ling Issue

/Seen 1
witin i

MH

Show

e/extra

Staff

Range

dition

No Note

PT not

on

Move Dupli.ca

Case ment/L te

Load/N ock

0

Down entry

Plevel

In Septeiliber 2016 58% detainees referred for Routine Psychiatry referral were seen within 14 days (in keeping with the tirneframe). 26% were released from CCDOC within the same timeperiod before Psychiatry had a chance to see them. 4% were seen by Psychiatry outside of the

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Appendix I\! The Agreed Order Status Update Page 7 of 55
timeframe (but within 30 days). Chart audit for the cases that did not have Provider's notes in EMR in1~eptember 2016 revealed that, when all the false positives and discharges from custody are subtracted, the actual number of detainees not seen as Routine Psychiatry Referrals in September was 23 (3.74% of the total number of Routine Psychiatry Referrals made).
In addition to existing vacancies in Psychiatry, the following major trends have been identified as a result of the 62 chart audit/review:
• Cemer continues to capture many IDOC transfers (most of them were parole holds upon admission to CCDOC)/Electronic Monitoring releases/Furloughs/15SFFP/, and extraditions as being physically on campus and, therefore, they are seen as "never having contacts with Psychiatry''. Dr. Kelner is addressing this glitch with IT.
• Scheduling and scheduling related errors remain an area of vulnerability. Cermak MH Leadership address scheduling issues with the Scheduling Supervisors.
• Some of the "No notes" were actually due to the fact that Cemer's logic was not timely updated and did not recognize one ofthe Locums' Providers name.
The interface between Cemer and CCOMS has been a standing agenda item in the monthly Interagency Coordinating Committee (IACC) meeting. A task list was created in August regarding discharge reactivations, which will resolve the issue of Cemer capturing transfers and facility releases. The CCSO and Cermak IT are finalizing the work contract with the third-party vendor. The interface will continue to be addressed in the IACC until the issues have been resolved.
Some challenges have been created by inappropriate requests for "Psychiatry Referrals" from MHS and PCC Providers for detainees already established on MH caseload, rather than the appropriate "Follow up with Psychiatry''. Dr. Kelner submitted a request to the JSH EMR committee to introduce a discern rule/change the referral careset in order to disallow non MH staff to eitder Psychiatry Referrals directly. A new power form has been built to accommodate that request. MH Administration also insists that every detainee who is referred to MH Department for services and evaluation, excluding crisis management, receives a structured Secondaf'j Mental Health Assessment (with the embedded Suicide Risk Screen/Suicide Risk Assessment) prior to ordering Referral to Psychiatry. Additional efforts have been put into educating Mental Health Specialists and PCC providers on the distinction between Referrals to Psychiatry and Follow up to Psychiatry. Ultimately, the goal is to enable only Mental Health Specialists to make appropriate referrals to Psychiatry.
MH Administration will continue to work with the Unit Directors and drill down the process so that MHS select appropriately a date within 14 days when MHS order Routine Psychiatry Referrals. The clerks/AAs responsible for the scheduling tasks do not always adhere to the 14 day timeframe. Education was provided to scheduling department as a group and individually. (Please see the Excel Appendix for data reflecting Routine Psychiatry Referrals).

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Appendix IV The Agreed Order Status Update Page 8 of 55
Daily reports for P Level detainees returning on the compound after hospital stays (15HP) are automatically generated and available to staff. They allow providers to identify detainees who reenter CCDOC and are in need of having their medications restarted as well as those who need to be assessed for MH stability by MHS so that appropriate housing is chosen.
Urgent Care Center continued to utilize their focal tracking system (FirstNet) allowing a more efficient control of the flow of detainees in UC. Now PCC Providers and Nurses can move detainees needing a MH assessment to the MH tab, therefore decreasing reliance on verbal hand offs and endorsements. Formally incorporating mental health into the flow of the urgent care will serve to minimize miscommunication, minimize missed assessments and minimize inappropriate discharge from UC.
Cermak and CCDOC has developed a collaborative process for the receipt of detainees returning from outlying counties:
1. Specific reception/processing time was designated: Saturdays 1.30PM as the start of ss::reening in RCDC
2. If Friday is a holiday, returns are back on the compound on Saturdays; if Monday is a
holiday, returns are back on Mondays 3. MH commits a MHS III to start the screening; at this point supported with OT 4. Vi!hen the rest of the RCDC team arrives at 3PM, they assist in processing outlying
county returns ifneeded 5. Every return to CCDOC must be screened by paramedics ("primary screening") 6. All detainees previously with P levels must have face to face ( "seen"), some M levels
will have medications renewed by Providers w/out being seen, if stable; additionally, new changes in clinical condition/new MH changes , need to have face to face 7. The following order will be followed MP's>P's>M's 8. Under certain circumstances, Medical can start seeing returns before MH, with the understanding that they may need to change orders from KOP to Dose x Dose later, in case detainees go into MH housing 9. CCDOC will assist in having PCs seen at the same time 10. Outlying Counties notify DOC liaison and RCDC Unit Director about upcoming arrivals and the list is distributed among RCDC MH staff 11. Outlying Counties provide medical records that arrive with the returning detainees 12. Chief of Psychiatry is notified of outlying county returns so that medications can be reordered.
Cermak mental health leadership previously identified several charges that warranted a DOC referral to intake mental health services. The charges included:
• Predatory Criminal Sexual Assault • Abuse of a corpse • Sexual relations within families • Dismembering a human body

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Appendix IV The Agreed Order Status Update Page 9 of 55
• Conspiracy to commit murder/solicitation to commit murder • Intentional homicide of an unborn child •· First degree murder when the following aggravating factors are present: killing of a peace
officer, murdering two or more individuals, murdered individual was less than 12 years
o;f age, matricide, patricide, the murder involved infliction of a torture, death resulted
from exceptionally brutal or heinous behavioral or wanton cruelty
DOC and Cermak mental health staffhas historically had a process by which intake correctional staffverbally informed Cermak mental health staff of any detainees charged with high profile crimes. In November 2016, the DOC formalized the process by creating an alert for a "DOC Intake Mental Health Referral" for all detainees with charges related to those mentioned above. The alert is entered by DOC RCDC staff and is communicated to the Cerner electronic medical record. Due to expressed concerns regarding the interface and the possibility of the alert not transferring to Cemer, DOC will continue to notifY Cermak mental health staff of such referrals verbally and through use of the alert until the interface issues are resolved.
November 2016 Metzner assessment: Significant improvement is noted re: meeting the required timeframes by the psychiatrists for completion of mental health referrals, which is the result of better tracking processes and supervision. In addition, processes have been implemented that have facilitated reviewing and obtaining relevant collateral information for mental health assessment purposes. The QI processes reported pertinent to this provision were very well conceptualized and very useful.
Recommendations: Continue to monitor the relevant timeframes specific to this provision.
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compli~ce Assessment: Partial compliance
Factual Findings:
April2016 Recommendations: Implement the plan for structured out of cell therapeutic activities for female RTU segregation inmates. Access to the patio and recreational yards should be significantly increased. It was my understanding that plans are being considered to winterize the patio area, which will provide for more access during the winter months to outdoor recreation.
RTU inmates continue to be offered at least 10 hours per week of structured therapeutic activities. The quality of some of these groups could be improved if new psychoeducational

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Appendix I\! The Agreed Order Status Update Page 10 of 55
videos could be obtained in order to supplement the current videos being used which have been viewed by many of the inmates in the past. The mental health services should have an annual budget for therapeutic programming materials.
Mental health staffing vacancies and allocation issues are directly related to inadequate mental health programming for protective custody RTU inmates
November 2016 Cermak Status Update
COMPOUND HOUSING PLAN BY MENTAL HEALTH LEVELS OF CARE (as of October 2016)
Cermak- P4 (Psychiatric Special Care Unit)- 2N acute male, 2W-acute and chronic female, 2S/2SE- male subacute, 2E- male chronic, P4 can also be housed on the third floor in Medical Special Care Unit under special circumstances. Housing on 3S for Mental Health reasons requires transfer orders from PCC/ Dr. Mennella. Patients with M4 and P4 can be housed on the Medical Special Care unit based on interdisciplinary decision.
• Division II: MALE MENTAL HEALTH HOUSING
• Dorm 2: Mental Health Outpatient P2; **if any Mental Health Intermediates (P3) are placed there, MH staff works on transferring them to RTU; CCDOC houses detainees that attend MHTC (Mental Health Transition Center) in Division II Dorm 2
• Dorm 1: NO MENTAL HEALTH HOUSING • Dorm 3: NO MENTAL HEALTH HOUSING
Dorm 4: NO MENTAL HEALTH HOUSING
• Division IV FEMALE MENTAL HEALTH HOUSING
o (Women's Justice- SWJP): FEMALE MENTAL HEALTH HOUSING- 1st Floor • Mental Health Intermediates P3 (requires clearance from DWJS staft) • Mental Health Outpatients P2 (requires clearance from DWJS staft)
o Mental Health Outpatient P2- 2nd floor
• Division V: NO MENTAL HEALTH HOUSING • Division VI: MALE MENTAL HEALTH HOUSING
o Westcare tiers- 2A/2B/2C (substance abuse, court ordered treatment program), Mental Health Outpatient P2
o Protective Custody: IA, IB and IC • Mental Health Outpatient P2 (only require mental health clearance prior to placement/ within 24 h if restricted housing rules apply) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division VI; they should only be cleared for PC in Division VIII RTU
• Division VIII RTU: MENTAL HEALTH HOUSING o 5th floor Females

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Appendix I\T The Agreed Order Status Update Page 11 of 55
• Mental Health Intermediates P3 (tiers B, F) Mental Health Outpatients P2 and DETOX (all other tiers)
• SMU (tier A) Protective Custody (tier E) (restrictive housing require mental health clearance prior to placement/within 24 h)
o 4'h floor Males • Mental Health Intermediates P3 (all tiers) • SMU (tier A) Protective Custody (tier E) • Mental Health Intermediates P3 (restrictive housing require mental health clearance prior to placement/within 24 h)
o 3'd floor Males • Medical Intermediate M3s (may also be P2s) with overflow Mental Health Intermediate P3s
o znct floor Males
• Mental Health Intermediate Overflow P3 (tier 2B) • Intensive Management Unit (tier 2A) • Division IX: MALE MENTAL HEALTH HOUSING o Protective Custody (Tiers 3E, 3F, 3G house alone/out alone/ admin. SMU, 3H PC) • If conditions of confinement are more restrictive than GP, Mental Health
Outpatient P2 require mental health clearance prior to placement/within 24h **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division IX; they should only be cleared for SMU in Division VIII RTU o SMU- non-administrative SMU (Tier lE; lF- enhanced security tier) • Mental Health Outpatient P2 (require mental health clearance prior to placement/within 24h) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to SMU in Division IX; they should only be cleared for SMU in Division VIII - RTU o General Population (all other tiers in the division) • Mental Health Outpatient P2 • Division X: MALE MENTAL HEALTH HOUSING: Mental Health Outpatient P2 **if any Mental Health Intermediates (P3) are placed there, MH staff works on transferring them toRTU o Protective Custody -1 C (meeting criteria of SMU housing) and 2C • **No Mental Health Intermediates should be cleared by mental health to transfer to SMU/PC in Division X; they should only be cleared for SMU in Division VIII RTU o Mental Health Intermediate Overflow P3 (2B); MH staf£'Bed Control teams from Cermak and CCSO works on transferring them to RTU once bed space becomes available • Division XI: NO MENTAL HEALTH HOUSING • Division XVI (Boot Camp): NO MENTAL HEALTH HOUSING; detainees on dose by dose medications cannot be in Boot Camp (and that excludes any patient on

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Appendix IV The Agreed Order Status Update Page 12 of 55
psychotropics)
Compound Housing Discussions: The planned transition to MHTC (Mental Health Transition Center) residential setting has not taken place.
On May 18, 2016, the DOC transferred the disciplinary segregation units in Divisions VI and X to Division IX in an attempt to centralize the restrictive housing units. Following this transfer, the units holding detainees that were found guilty of disciplinary infractions were truncated from four divisions to two (Divisions 08 RTU and 9), allowing for a centralization of services.
CCHHS partuered with the Cook County Justice Advisory Council and the Chicago Police Department in the opening of a pilot Community Triage Center in the Roseland neighborhood. The community-based center provide evaluation, crisis stabilization and treatment referrals for patients presenting with psychiatric and/or substance-related emergencies, and will work closely with the local hospitals and outpatient mental health services to best meet patients' needs 24/7/365 in order to prevent detentions and hospitalizations. Access will be prioritized for police officers to drop off individuals and rapidly return to their patrol areas. A primary goal is to reduce a number of detainees admitted to jail who have an identifiable behavioral health condition by providing a treatment oriented alternative to detention. The CTC will also provide walk-in services for those released from the Cook County JaiL
Updates: RTU Male Services Psychiatric services in Male RTU have been constant. Staffing levels in the high priority area (RTU) constant are maintained for P3 detainees. In response to concerns about the frequency of follow up in Divisions after PSCU discharges, Psychiatry has introduced a new paradigm when detainees dispositioned to P3 and P2 Levels of care are followed by MHS in one week, and by Psychiatry in 2 and 4 weeks.
Cermak continues to strive to modifY conditions of confinement for those who are housed on 4A (SMU tier). A random sampling established that of October 17th, 2016 RTU 4A (mixed tier/some are M level patients/all classes) average length of stay was 5.15 days, without two outliers; with the outliers it is 14.93. One of the outliers is M3 and had 69 days of continuous disciplinary time (he was not sent to Cermak for mitigation) and the other one, a P3 was housed on the tier for 88 days with two tickets sent for mitigation (last one in August) and was mitigated to 7 days of SMU. Further investigation revealed that he was no longer being considered a disciplinary segregation detainee by custody, but rather a house alone individual.
Modification of conditions of confinement for those individuals with Serious Mental lllness whose time in SMU exceeds 14 days would consist of providing more out of cell time to them, however, DOC Disciplinary Unit continues to issue tickets for P3 that do not exceed 14 days. Cermak continues to provide structured therapeutic programming for SMI detainees in SMU 4A, further described in the updates. Detainees remain tethered to stationary furniture during out

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Appendix IV The Agreed Order Status Update Page 13 of 55
of cell group structured therapy/activities. As more staff allocations become available, Cermak will continue to target 10 hours of structured activities 110 hours unstructured activities provided to these detainees.
Since April of2016, RTU Male Services has made several changes to the treatment program based upon DOJ recommendations, feedback from detainees, and the clinical needs ofP3 overflow. An overview of programming is outlined below.
Over the past year, efforts have been made to provide more individualized treatment for P3 detainees housed on the fourth floor ofRTU. While detainees previously attended group by bed number, adjustments were implemented in November 2015 to offer voluntary groups. This system allowed detainees to sign up for specific groups based upon clinical need. As mentioned in the su1nmary outlined in April of2016, this format seemed to increase motivation for many detainees. However, ensuring equal participation in groups across dorms became challenging. To illustrate, some detainees attended numerous groups, while others only signed up for a few. Further adjustments to the schedule were made in May of2016 to address imbalances in group participation and the logistical issues of tracking attendance as detainees transferred from dorm to dorm.
Currently, the RTU male treatment program blends voluntary groups with those conducted by group number. The mental health team identified three core clinical areas that benefit all of the population referred for intermediate care: emotional management, communication/interpersonal skills, and problem solving skills. Detainees on five of the P3 dorms are therefore scheduled to attend these three groups based upon bed number. Each detainee was then asked to rank order their preference for voluntary groups, with the understanding they would attend at least two additional groups ideally of their highest rank ordered choices. Based upon feedback from detainees and clinical staff, the following groups were offered as voluntary groups on five of the dorms: MISA/Recovery, Positive Psychology, Community Re-entry, Young Men's Group, Progressive Relaxation, Grief and Loss, Intrusive Thoughts/Mindfulness, Book/Joumaling Club, and Chair Yoga/Meditation. The sixth P3 dorm (4B) is designated for lower functioning patients who largely participate in on tier programming focused upon hygiene, medication compliance, and basic life skills. Progressive Relaxation and Emotional Management are offered as off tier groups for this dorm. All detainees are also encouraged to attend on tier groups (Rise and Shine, Community Meetings, and Movie Group) as well as off tier art therapy sessions. Verification letters are given to detainees on all dorms who attend at least 75% of their groups. In the past few months, 17-30% of detainees on dorms have earned letters for their participation. The variety of clinical services offered is a strength of the blended treatment program. Detainees benefit from the opportunity to participate in structured sessions as well as experiential practice ofbreat~ng, stretching, reading, andjoumaling. Mental health staff were asked to choose modules,of their own interest, which seemed to enhance their motivation and sense of accountability. In the future, the mental health team will focus upon developing uniformity in content and structure ofmodules.

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Appendix IV The Agreed Order Status Update Page 14 of 55
MH stafi(itcontinue to provide group programming on 4A, a Special Management Unit. This tier remains the only SMU unit for all males in Division 8, which results in periods of mixed housing for P3, P2, and general population detainees. At times, the unit has no P3 detainees. As a result, interest and participation in group varies, often depending on who is housed on the unit. Further, behavioral incidents on 4A increased for several months, largely due to the housing of detainees who were usually placed in Division 9 and were temporarily receiving medical care in RTU. Those particular detainees repeatedly engaged in problematic behaviors (flooding, climbing the shower, refusing to lock up, etc.) to obtain secondary gains. These incidents often interfered with group progranuning. Another issue that caused some complication was the increase in out of cell time for detainees in SMU. When this positive change initially occurred, some groups could not be conducted as detainees were frequently completing hours out throughout the day. MH staff have since collaborated with tier officers and adjusted group times, which has been more successful on the 3 to 11 shift. Day shift staff tend to encounter multiple competing activities (law library, CRW, hearing board, movement, etc.) and have been working to make up groups whenever possible.
A significant challenge to consistent group progrannning on all tiers has been mental health staffing. Prior to August of2015, the RTU treatment team comprised of thirteen MH staff (both MHS ITs and MHS IIIs) who provided group programming for six P3 dorms in addition to other clinical activities (MH clinic, HSRF' s, P3 rounds, SMU rounds, individual contacts, and crisis intervention/psych evals). Since November of2015, the RTU treatment team has been responsible for progranuning on four additional tiers including 4A (Special Management Unit), 2A (Intensive Management Unit), 4E (Protective Custody), and 2B (P3 overflow). Providing these additional services with the same number of staffhas been challenging. Further, the mental health team has been short three staff since July 2016 due to displacements, turnover, and extended absences for health issues/bereavement. Consequently, the team has not been able to fulfill projected goals for group programming. Staff absences have additionally impacted the consistelj\cy of clinical programming. To illustrate, only two MH staff are currently assigned for RTU-Males on Fridays and Saturdays (both AM and PM shifts). In the event of a planned or unplanned absence on either shift, the remaining MHS often has to cancel group in order to attend to psych evals, emergent HSRFs, and SMU clearances for all three floors. MH staff frequently express concerns about prioritizing clinical demands with fewer staff available.
CCDOC staffing has also impacted group programming on the 3 to 11 shift over the past few months. In April of 2016, a trend of evening group cancellations emerged. In particular, MH staff noted they were not able to conduct off tier sessions due to lack of movement officers to supervise groups. There are four to eight off tier groups scheduled from 4pm to 6pm on most nights depending on the number ofMH staff assigned to the shift. During that time period, movement officers are often pulled for recreation, tier searches, and other duties. Periodically, movement officers return and staff are able to conduct group as scheduled. At other times, movement officers return as other activities on the tiers begin including dinner trays, barber shop, and on tier movies, all of which further interfere with group programming. Although staff are encouraged to make up groups on the tier whenever possible, evening staff are typically left

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with large numbers ofHSRFs (between 20-50). Consequently, they usually begin attending to HSRFs and psych evals, which then potentially interfere with their availability to return to group even when officers become available. The lack of movement officers and CCDOC staffing has been discussed in several interagency meetings over the past few months.
In recent months, several conflicting activities seemed to contribute to group cancellations and/or diminished participation in group sessions. Specifically, tiers being taken to recreation during group time and on tier movies being played during scheduled groups on the evening shift. Detainees were understandably less motivated to participate in group sessions when choosing between these activities, which ultimately resulted in increased cancellations. These conflicts have been discussed in interagency meetings. Fortunately, cancellations due to recreation have decreased with "real time" communication ofthese instances. Most recently, MH and CCDOC partuers agreed to collaborate on a joint schedule to outline time periods for group sessions, recreation, tier searches, etc.
Bed spase remains a significant issue for P3 males. Although an overflow dorm was created on the second floor ofRTU (2B), this housing is shared with medical patients and is not sufficient for the number ofP3 males awaiting a space on the fourth floor. Consequently, the number of detainees placed on 2B and other tiers within RTU typically varies between 20 to 40 detainees. In addition, Division 10-2B has opened an overflow dorm for P3 males, which also houses anywhere between 15 to 20 detainees.
During weekly MDT meetings, staff attempt to identify detainees who are stable to transition out ofRTU. Several issues arise during those discussions. The level offi:mctioning amongst P3 detainees vary widely. Many males are referred to intermediate care due to chronic mental illness. These detainees often require assistance with basic self-care, medication compliance, and symptom management. Other detainees are otherwise higher fi:mctioning with histories of mental health treatment in the community or demonstrated difficulties adjusting to incarceration. MH staff often struggle with treatment planning for detainees who are mentally ill yet unresponsive to and noncompliant with clinical intervention. Alternatively, some detainees are quite high fi:mctioning and are stable for less restrictive environments, but seem to benefit from participation in treatment. Ideally, higher functioning detainees will have shorter lengths of stay and can be transferred out ofRTU more quickly. However, many of the detainees become comfortable in the dorm setting and resist being transferred to what they perceive as less desirable, celled housing. For example, several detainees openly admit to exaggerating or feigning symptoms and to acting out to remain in RTU. As a result of these efforts, many P3 detainees successfully obtain preferential housing and remain in or inunediately return to RTU. Consequently, the P3 detainees in overflow housing are then delayed in their transfer to the fourth floor. MH staff is scheduled to provide follow up, community meetings, and/or rounds for overflow detainees at least three times per week, which helps to monitor patients and identify those in need of immediate transfer to the fourth floor. However, aforementioned staffing issues impacts this oversight.

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To address challenges with overflow, the MH team will need to develop greater clarity and consensus on the clinical needs ofP3 versus P2 detainees. Additionally, the RTU MH team will begin focusing more heavily upon treatment plan review in MDT meetings to identify detainees who havt( completed group modules and have made sufficient progress on outlined goals. This type of review will ensure that all detainees are systematically assessed for step down. Moreover, MDT staffing with Div 102B "ill help to identify detainees who may have stabilized and may not need transfer to RTU. The team has also discussed that Div 102B can eventually serve as P3 housing for detainees who are not appropriate for a dorm setting. In this way, Div 10 can function less as overflow and instead provide the appropriate treatment setting for more labile and aggressive detainees. This will also be resource and staff allocation dependent. Ongoing collaboration with CCDOC will be also important to manage bed space issues. In the past few months, the newly developed system of directly contacting classification has been effective to expedite requested movements.
Updates: Intensive Management Unit
The Intensive Management Unit (IMU) is on the second floor or RTU. This specialized program is designed to provide increased structure and support for mentally ill detainees who have demonstrated significant problems in their functioning. The program consists ofthree successive phases (Assessment and Admission Phase-minimum 2 weeks; Stage 1- minimum 4 weeks; and Stage 2-minimum 4 weeks) which offer increased incentives as the detainee progresses. Recently the 3rd Phase (Residential) was introduced to accommodate program graduates who have lower functioning/significant deficits and expected to do poorly in the dormitories in RTU. All of the detainees selected for the program thus far incurred notable segregation time due to severe behavioral problems (e.g. assault against others; property damage; sexual misconduct; threats and noncompliance). These detainees were informed their participation and successful completion of the program could result in absolution of segregation time for previous disciplinary tickets. The first three detainees moved into the IMU unit in October of2015. The program continues to offer more than 15 hours of structured out of cell therapeutic programming. Dr. Kaniuk is the Unit's Director. Dr. Keloer temporarily served as a Psychiatrist. Effective October,~016, Dr. Haq is the new Unit Psychiatrist.
The IMU team meets for weekly MDT meetings and holds on tier meetings with the detainees every week to review treatment progress and expectations. The collaboration and communication amongst this disciplinary team has been essential to facilitate the progress of detainees. A joint manual for both MH and CCDOC staff is being developed to address the issues and questions that have arisen over the past six months. Currently, the team continues to work on maintaining consistency across shifts and personnel. Security personnel who are assigned to IMU must have knowledge ofthe program because participants have entitlements that are consistent with their level in the program, including how they are secured in the dayroom. Their level in the program also dictates which commissary products they can purchase. The first shift is fairly consistent and the officers work well with the program detainees. On other shifts, the same officers are not assigned to the unit, which creates inconsistency. Unfortunately, many of the

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behavioral problems occur on the second and third shifts. Mental health staff work well with security. A walk around tour with Facilities Management and DOC leadership identified physical plant inefficiencies. Jn order to repair those structural defects additional modifications and caulking are pending.
Further, limited space and computers make it difficult to conduct all clinical activities and charting on days when all staff is present. Requests have been made to activate the computers on the second floor to allow access to Cemer and for mental health staff to be able to utilize computers in the medical triage rooms on the tier, particularly as MH presence continues on 2A and 2B. Overflow is sometimes placed in IMU overnight (mostly due to bed shortages in RTU). Issues pertaining to overflow include:
1. Confidentiality issues. When detainees participate in therapeutic out of cell programming, there is an expectation of privacy, very much similar to the instances when individual therapy is conducted. When Cermak staffprograms in spite of the overflow presence, lack of privacy has a chilling effect on detainees and inhibits their ability to participate in therapeutic activities.
2. Group disruption! cancellation due to overflow detainees needing to have their time out.
3. Detoxification cases placed in IMU are rather labor intensive in terms ofNursing protocols (COWS and CIWA) and disrupt out of cell programming.
4. When overflow detainees are housed in IMU by DOC, an effort is made by CCSO Bed Control and Classification staff to move them off IMU as early as possible and, preferably, before group activities are scheduled to start around 9am.
Currently, two groups are held Monday through Friday mornings. Another group is held in the evening when staffis available. Group content includes positive psychology, anger management, communication, DBT, etc. CRWs come to the tier on a daily basis.
Staff availability is a significant problem. There are employees assigned to do groups from the fourth floor ofRTU during the 7-3PM shift but due to vacation and sick time, they are often absent. In addition, groups may be cancelled due to medication pass, overflow detainees being transferred, power washing of cells, or other behavioral issues. If there are any emergencies, mental health workers assess the patients on the tier, either cell front or at the nursing medication window. When staff are unavailable onsite, all emergencies are seen in Urgent Care. At times, the detainees engage in behaviors with the goal of going to the Urgent Care area or outlying hospitals for a variety of secondary gains. These issues include self-injurious behavior, suicide hanging, foreign body insertion/ingestion, jumping off ledges, slipping in shower, eating magic shave foam, and banging head.
The medical social worker in the building addresses family issues, discharge medications, and
f'

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provides linkage services to community agencies.
Updates: f,emale Services
Cermak continues to provide Psychiatric Services to the mix ofP3, P2, and SMU populations. Psychiatrists continue to provide services to the SWJP participants (remanded to the program by the Courts) and the remainder of the female detainees with mostly P2 and some with P3 level of care. Clinics are run separately as detainees are separated in terms of housing. Most of the clinical services for SWJP participants are provided by a Contractor - "Salina and Associates". Division IV did not have not have SMU until recently when a PC unit was opened. Dr. Briney is the Unit Director. Psychiatry FTE is 0.5. MH Population: P2-182 and P3-7.
Currently averaging 7.2 hours per patient per week for intermediate level of care due to the reduction in staff. Cermak and SWJP treatment staff are working well together and have increased communication, providing improved treatment for all Div. 4 patients. Communication between mental health and CCDOC has greatly improved. Enrichment programs have been implemented for P2 and GP patients (Book Club, Theater Group, Anger Management, Yoga, Legal Aid, and sewing workshop). Superintendent Baker has been instrumental in improving multidisciplinary communications and increasing enrichment programs. P2s continue to be spread among the second floor rather than on two tiers. Lists of P2s/GPs who need to move are provided to security approximately every two weeks, but moving patients in div. 4 seems to occur more slowly now that they are not handled at the local level. However, there are very few moves that are occurring between divisions, improving compliance with appointments and decreasing patient stress. Div. 4 provides a helpful daily list of all patient moves in an effort to ensure appointments are rescheduled._Patients generally prefer tier housing. Housing units in RTU are being regularly power washed. No recent temperature complaints. Ongoing religious services are provided and CCDOC provides weekly Enrichment groups for P2 patients. Patient in the two divisions make some attempts to move to the other division to obtain preferential housing, but patient moves have been minimized greatly.
Patients meet with their tier mental health specialist to create a treatment goal list. Each P3 patient is discussed in MDT staffing on a regular basis. Patients receive treatment cards (also to motivate patients) and to ensure they are aware of their treatment plan. Both the patients and the entire treatment team are involved in the treatment planning process, resulting in individualized treatment plans for each P3 patient. Nearly all (99%) ofp3 treatment plans are initiated and updated on time. The quality oftreatment plans has improved. Outpatient (P2) treatment plans are in compliance, as they are created by psychiatrist the treating psychiatrist during clinic appointments. P2s average 2 hours of group per month in Div. 4 and RTU.
Patients receive a face to face assessment generally within 48 hours ofreceipt of the HSR by a MHS III. When staffing is low, there are some HSR that are completed outside of the 48 hour range. Patients have increasingly demonstrated misuse/abuse of the HSR process. There has been a large increase of patients making demands for specific medications. They are submitting

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multiple requests daily for the same issues. Usually, "anxiety" and "I can't sleep." Many patients make statements like, "I'm going to keep putting these in every day until you give me what I want." Community groups, HSR contacts, and psych evaluations are frequently including sleep hygiene, anxiety management, and relaxation! coping skills, but many of the patients are hyperfocused on receiving specific medications.
Cermak continues to strive to modify conditions of confinement for those who are housed on SA (SMU tier). A random sampling established that of October 1J'h, 2016 RTU SA (mixed tier/some are M patients/all classes) average length of stay was 8.17 days. Average number of disciplinary tickets from January 2016 to date was S.7S. Modification of conditions of confinement for those individuals with Serious Mental lllness whose time in SMU exceeds 14 days would consist of providing more out of cell time to them, however, DOC Disciplinary Unit continues to issue tickets for P3 that do not exceed 14 days. Since the last site visit, patients in SMU and protective custody have received one hour of mental health progrannning per week. In non-PC SMU, the unit director facilitates weekly group. Patients are blue boxed for safety purposes and there is an expectation that there will always be two officers present on the tier during group. Patients have generally been receptive and ask for more programming. More programming has not been possible due to current staffing challenges. Although P3s are the priority for SMU groups, others are permitted to attend. We have learned this creates a more challenging situation given that SMU ranges from general population to intermediate mental health. There have been issues of higher functioning patients targeting and taunting lower functioning P3 patients. This interaction has not been avoidable given that females only have one non-PC SMU on the compound. The higher functioning GP and P2 patients also have difficulty benefitting from group b~use their peers are lower functioning in terms of mental health. This was also previously an issue with protective custody, in addition to a lack of SMU bed space.
Since the opening of a protective custody in Div. 4, we are seeing more cohesive mental health groups and interactions on the PC tiers, as well as less manipulations for preferred housing between divisions. With the planned increase in mental health staffmoving to female treatment divisions, we are scheduling 10 hours of structured mental health treatment activities and additional time out of cells in both disciplinary SMU and protective custody beginning 12/1/16. The tier mental health specialist will also be responsible for ensuring P3 patients receive a monthly individual contact and treatment plans will be entered by the tier MHS, just as on intermediate mental health dorms. The mental health team will continue to stress the need for increased number of security staff to provide observation and security, which has been challenging, particularly on the 3-11 shift. Rounds are completed once per week (PC and SMU). Patients are assessed by MH within 24 hours of placement in SMU. There have been recent challenges with security not referring patients to mental health when they are to be housed in SMU, resulting in delayed mental health assessments. Patients in both Protective Custody and SMU receive an average of 1 hour of group per week due to current staffing allocations.
A significant number ofP3 and P2 patients receive individual therapy services in RTU and in Div. 4 for more personalized treatment. Due to current staffing allocation, there are fewer slots

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and longer wait times. Each P3 patients is assigned to meet with her tier mental health specialist
monthly for an individual mental health contact. Approximately half of the P3 patients regularly receive the monthly contact. The discrepancy appears to be a function oflimited mental health staff, staff motivation/time management (addressed in individual supervision) and lack of security on the evening shift to provide security during individual contacts. The RTU provides 24 hour on-site psych evaluations and consultation. We are trying to improve consultation with CCDOC to refer appropriate psych evaluations according to policy (emergent issues, use of force, placement in special management unit, suspected or confirmed physical or sexual abuse). Unit Director periodically attends roll call to discuss psych evaluations and referrals and to remind all staff of the existing interagency agreements and policies. Mental health is putting a flow chart together with the assistance of our program analysts to provide a simple visual rerninden:ofpolicies for appropriate referral for psych evals.
We continue to focus expressive arts and linkage services on P3 patients. An additional expressive arts group has been added for tier SB. P2s receive limited linkage services and discharge medications. Overall, we have seen improvement with patients who have poor hygiene. Currently, the rise and shine program occurs one day per week rather than the previous five days per week. Hygiene supplies and encouragement are provided. Patients displaying ongoing, serious hygiene concerns are discussed in MDT clinical staffing and are admitted to the psychiatric special care unit for increased support and a humanitarian shower. Female Services has a very low self-harm rate. Self-injuries that do occur are most often housed in disciplinary segregation. Female services has seen some increase in self-injury in segregation (P3 and very stable P2s), as they believe it will get them out of segregation and placed back on a tier. Patient motivation continues to poses challenges. Mental health facilitates a movie discussion group for treatment compliant patients every two weeks. We are also providing a standardized letter ofparticipation monthly for patients attending 75% of recommended treatment groups. Few women (10-15%) are receiving the letter of participation due to lack of consistent attendance. Long-term patients (particularly SF) want new treatment videos and materials, reporting that they are bored. Despite ongoing and prior efforts and external motivators, the staff finds that only the women who are intrinsically motivated to participate in treatment are attending groups. The remaining patients enjoy sleeping and socializing on the tier.
There have been some informal complaints and formal grievances received about specific mental health staff with patient reports that they too frequently show videos for group or are not as respectful as they feel they should be. Such issues have been addressed in individual and group supervision. Mental health administration has also been made aware. Facilitating interactive groups has been discussed in group supervision. Concerns specific to CCDOC, specifically about the availability of officers and/or consistent presence at identified posts, has been raised at division~ meetings with CCDOC leadership. Additionally, CCDOC has been informed of specific security staff who have displayed patterns of inability to work effectively with mentally ill patients or mental health treatment staff. Patients will sometimes report being bored on the tiers to the mental health staff. Patients have periodically complained to mental health staff about being unable to have recreation in RTU when the weather is cool or have complained that

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1,,iJ
is recreation inconsistent. Additionally, to address clinical programming conflicting with recreation, mental health periodically resubmits the schedule of group times to CCDOC supervisory staff.
Updates: Division 2 Dorm 2 Division Two- Dorm Two houses P-2 and M2 (outpatient level of care) patients within a dorm setting. There are ten dorms over three floors, with a census of approximately 44-48 detainees in each tier. It includes detainees with minimum and medium security classification. Services are maintained 'mthout significant changes. MHTC detainees are housed in the V house. Overflow P3 are rarely housed in Division II Dorm 2 until a bed opens in RTU and Cermak staff facilitates transferring detainees to RTU with the help of CCSO Bed Control/Classification staff.
Telepsychiatry Clinic continues to provide reliable coverage for this Division and remains the strongest assignment in terms of productivity and meeting departmental expectations. Dr. Ward sees patients on a daily basis, with a combination of new evaluations and follow-ups. Dr. Marri is in Division Two- Dorm Two for one-half day per week and usually sees detainees who need translation services.
Supt. Martinez has been very open to the needs of mental health. Dr. Kaniuk functions as a Unit Director for Divisions VI and II. Dr. Kaniuk is the Unit Director. Psychiatry FTE is 1.1. MH Population: P2-409.
A dorm setting makes it easier for detainees to talk to the staff, since they are often within proximity of the detainees. Because detainees have immediate access to staff in the open setting, many of the requests made are not related to mental health. Thus, the limited staff could become overwhelmed. In addition, security will often refer detainees for non-emergency requests to mentallj,ealth staff for immediate evaluation using interagency health inquiry forms. The physical'plant also poses challenges. There are only two interview rooms on the second floor, one is being used by telepsychiatry Monday through Friday. As such, it becomes more difficult to see detainees in a private setting. Quite often staffhave to interview detainees outside the tier in any available space.
Staff availability is also a challenge. There are two employees assigned during the 7-3PM shift, but due to vacation and sick time, they are often absent. All mental health requests during the 3llPM shift or 11PM-7AM shift are seen in Urgent Care.
Groups are scheduled on a weekly basis in all ten tiers. It is composed of two parts: community issues and therapeutic intervention. The types of groups conducted are anger management, substance abuse, domestic violence, criminogenic thinking, and depression. However, due to absenteeism and other issues (nursing staff passing medication, security passing out supplies, linen exchange, commissary, emergency evaluations), it has been difficult to meet the target of one group in each tier per week.

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Security refers individuals who request an evaluation or have a question, as well as those who display behavior problems. This is done formally (Inter-Agency Health Inquiry) and informally. The mental health staff, along with the CRWs, meet with Supt. Martinez on a weekly basis.
There is a psychology clinic scheduled for Tuesday mornings. There are no problems seeing detainees in this clinic. Mental health clinic occurs on Wednesday and Thursday mornings. One mental health specialist is assigned to this clinic and it runs rather smoothly.
The nursing staffprocesses HSRF forms before giving them to mental health staff. However, on occasion, there is a delay in processing the forms. The detainees who write these requests are seen by the mental health staff (MHS III or psychologist) in a timely manner. Mental health staff or the medical assistant will inform nursing staffwhen a "STAT" order has been written by psychiatry.
There is.Ji medical social worker assigned full-time to work in the building. He addresses family issues, discharge medications, and provides linkage services to community agencies.
Updates: Division 6 Division Six houses P-2 and M2 (outpatient level of care) patients, along with GP (General Population) detainees. The Protective Custody tiers (1-A, 1-B, 1-C) and the Westcare substance abuse program (2-A, 2-B, 2-C) P-2 detainees. Division VI no longer houses Special Management Units (Non PC), they were moved to Division IX . The PC population includes detainees with special accommodations. As the population ofP2 detainees grew, Psychiatry allocations were increased to accommodate the increased need. Dr. Kaniuk is the Unit Director. Psychiatry PTE 0.3. MH Population: P2-202.
There is one mental health specialist assigned during the 3-llPM shift (Sunday through Thursday), but due to vacation and sick time, she is occasionally absent. Also, the MHS III may be reassigned to the Cermak building or RCDC, should the need arise. Community meetings have resumed with the allocation of a security escort and are scheduled for Tuesday and Wednesday. The meetings contain two components: community milieu issues and clinical topic. The group topics include substance abuse, anger management, criminogenic thinking, domestic violence, and depression.
Security refers individuals who request an evaluation or have a question, as well as those who display behavior problems. This is done formally (Inter-Agency Health Inquiry) and informally. The unit director (psychologist) and other disciplines meet with Supt. Beachem on a weekly basis.
There is a psychology clinic scheduled on Monday mornings. Security brings the detainees on a timely basis. Mental health clinic occurs during the 3-llPM shift on Sunday, Monday, and Thursda):', There have been no difficulties reported about this clinic.

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The nursing staff processes HSRF forms before giving them to mental health staff. During the morning shift, the forms are faxed to Urgent Care and emergencies are seen as soon as possible. The non-emergency requests are processed by Urgent Care and scheduled for mental health clinic in·pivision Six.
There is a medical social worker assigned to work in the building. She addresses family issues, discharge medications, and provides linkage services to community agencies.
Updates: Division 9 & 10
Since the last visit a new Unit Director/Correctional Psychologist has taken over leadership ofthe Div. 9 & 10, Dr. Elma Augustine. The following services continue to be provided in Division 9, Super Maximum, and in Division 10, Maximum by Mental Health Specialists and a psychologist: evaluations and treatment for mental health conditions, psychological evaluations and assessments for suicidal risks. This clinical team provides therapeutic services which includes mental health clinics, group therapy and the following: treatment planning for intermediate level detainees, community meetings for outpatient detainees, segregation clearance for Special Management Unit admittance, weekly Special Management Unit Rounds, crisis intervention and processing of detainees mental health needs that are documented via Health Service Requests and Inter-Agency Health Inquiries forms.
Special Management Units for non P3 detainees are now exclusively concentrated in Division IX. SMU Units from (Non PC) from Divisions VI and X have been moved to Division IX. SMU housing includes special managements tiers (Non PC) and Protective Custody tiers. P2 detainees are diffusely housed also on non SMU tiers throughout the building. Detainees identified as institutional threat and engaging in actions designed to disrupt operations are concentrated on IF and 1E where enhanced security parameters are enacted with enhanced movement and security precautions. It was clarified by CCDOC Leadership that the qualifYing behaviors must not be rooted in or related to mental illness. Those with serious staff assaults, serious inmate assaults and thos~. that repetitively disrupt CCDOC operations are housed there.
• The Patient Safety and Enhanced Security Guidelines for patients who present with self-harm (Foreign Body-ingestion, insertion and pill ingestion) in Division IX was designed to complement the enhanced security parameters and reduce the amount of disruption of operations. Analogous Guidelines for Management ofPatients after Foreign Body Ingestion have been developed as a result of a collaborative effort between CCDOC, Department of External Operations, Cermak Administration, John Stroger Hospital Risk Management Department, JSH Emergency Room staff, and JSH Gl/ Internal Medicine Department. These guidelines operationalize transfers, observation, alimentation, and treatment of patients engaging in frequent self-injurious behavior, for non-suicidal reasons.
lo SMU new measures have been added to further improve security and staff safety while modifYing conditions of confinement: a. moving Dose by Dose Patients to the first level of those

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AppendixN The Agreed Order Status Update Page 24 of 55

tiers. b. having 5 officers and a sergeant working on those tiers at all times c. CCDOC staff completing rounds every 30 minutes on those tiers d. Cermak Patient Care Services (PCS) staff completing medication pass at the cell front e. Cermak PCS staff having a CCDOC escort and medication pass officer with them at all times. £no detainees are out of their cells when Cermak staff is on the tier. g. Cermak PCS staff will complete the morning/evening passes medication pass by certain time to give DOC more certainty and preparation for adequate staffing/including supervisory staff

Cermak MI-I Department will furnish SMU detainees with the services, as elsewhere described in this report:

a. SMU rounds weekly (in addition to weekly PCS rounds) b. Psychiatry appointments (regularly scheduled and walk ins) c. Individual Behavioral Management Treatment Plans d. Other essential services -individual supportive counseling , access to emergency and
routine care as per DI-ICR process, crisis intervention, etc. (commensurate with their level of care)

Cermak Mental Health started limited structured out of cell therapeutic programming on IE utilizing.the services of one staff Psychologists. IE has been retrofitted to allow detainees to be secured to stationary furniture during group therapy. Dr. Augustine is the Unit Director. Psychiam; PTE 0.2. MI-I Population: P2-178.

Special Management Units (Non PC) have been moved out of Division X. I C and 2C continue to house Protective Custody Imnates. Elsewhere in the division, on non SMU tiers, Cermak continues provide Psychiatric Services to P2 populations. 2B remains an overflow tier housing P3 patients until a bed becomes available in RTU. Utilization of Division X 2B as P3 overflow has decreased with the opening ofRTU 2B as a P3 overflow tier in September 20I5, however consistently maintains a census that fills half of the tier. Telepsychiatry clinic is open in Division X three days a week utilizing 0.6 PTE of a Locums Provider and a Locums Telepsychiatry Clinic Attendant. In a significant development, DOC staff now supervises afternoon Psychiatry clinics 3 additional days a week with the resultant improvement in access to care:

Monday Tuesday Wednesday Thursday Friday

8.30AM- 12.00N (both classrooms) 8.30AM- I2.00N (both rooms) 8.30AM- I2.00N (both rooms) 8.30AM- 12.00(both rooms) 8.30AM- 12.00(both rooms)

l.OOPM-3.00PM (one room) 12.30PM-4.00PM (both rooms)
l.OOPM-3.00PM (one room).

Physical Plant changes have been undertaken: DOC Facilities management installed walls rings in the rooms that host Psychiatry clinics and now detainees are secured to stationary object during the session. Detainees with CCOMS and Cerner alerts denoting dangerousness and affiliation with the Savage Life jail gang now presented to Psychiatry Clinics with enhanced

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supervision by DOC staff. Environmental Services extended the cables of landlines and computer terminals in those rooms and that enabled reorientation of Provider's desks so that more efficient escape routes were opened to Providers. Unit Director: Dr. Augustine. Psychiatry FTE is 1.3. MH population: P2-495.
There are currently two Mental Health Specialists in Division 9, one on the am shift and one on the 3-11 pm shift. They provide services to 24 Tiers. In Division 10 there are five Mental Health Specialists, three on the am shift and two on the 3-11 pm shift. They provide services to 16 Tiers, one of which is an intermediate level of care tier functioning as overflow for P3 patients awaiting bedspace in the RTU. One psychologist is assigned to both divisions.
Accomplishments are reflected in weekly provision of the above listed services and weekly provision of: Mental Health Specialist Clinics six days per week in Division 10 and five days per week in Division 9, weekly Psychology Clinic on Mondays in Division 9 and on Wednesdays in Division 10.
Groups are conducted by Dr. Waxler on Division 9/1 E on the first and third Tuesdays ofthe month. In Division 10 the group/community meeting schedule is nine groups weekly, (3 on Tuesdays, Wednesdays and Thursdays) with an expected total of 32 groups per month. Groups were previously held on the living units. It should be noted that groups in Division 10 were suspended by mental health administration effective August, 2016 due to acute security concerns following a sentinel event. However, since then a plan reflecting increased safety during the facilitation of services was able to be agreed upon and groups were resumed on October 19th. The groups are now help off-tier in the division chapel. Initial restart of programming was marked by some miscommunication of expectations, however with the assistance of divisional correctional leadership groups did occur as scheduled on 10/19 and 10/20 and a total of 37 detainees participated in off-tier groups during these two days. Moving forward, in an effort to ensure that all staff are informed and participants are prepared for groups, Supt. Walsh and Director Reyes agreed to have the group schedule announced daily in roll call. Additionally, Mental Health staff posted a scheduled of the groups on all Tiers.
The following challenges impact the delivery of mental health services in Divisions 9 and 10. The historical presence of Mental Health Specialist staff available for 11 pm to 7 am shift for both Divisions was beneficial in addressing overnight crises onsite and in minimizing the need for moveme~t out ofthe building, which can serve secondary gain. With the current allocation oftwo mental health staff for Division 9 (one on the 7 am- 3 pm shift and one on the 3 pm to 11 pm shift) it is difficult to meet the high demands of a population that includes special management units, behavioral issues and enhanced security tiers.
The current provision of care is being impacted by current staffing allocation. Following displacement of and subsequent reassignment of staff in June 2016, the division lost the mental health specialists responsible for morning clinics in Division 10 and intensive supportive services to intermediate level of care detainees/ P3 's housed on Tier 2B Division 10.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 57 of 110 PageID #:5187
Appendi.;>i. PV The Agreed Order Status Update Page 26 of 55
The physical plant in both divisions is also a challenge for mental health staff. There have been ongoing challenges with securing designated clinic office space for Mental Health Specialist or Psychologist to consistently utilize in Division 9. This impacts the provision of mental health services on a weekly basis. There is an office space available for Mental Health in Division 10. However, the space is extremely small and results in an uncomfortable and potentially unsafe space between staff and detainees. Mental Health administration continues to work with Cermak and CCDOC administration to rectify space issues.
In Division 9 a challenge for mental health is clearance ofdetainees for Special Management Unit Admissions (SMU). Mental Health Specialists (MRS) have encountered difficulties in ensuring 100% compliance in Segregation Clearance due to the following: MRS are not always informed in real time when a detainee is being sent to SMU or when the detainee is removed and returned after 30 days/24 hours out compliance. Another challenge is that mental health is often not informed that detainees are being placed in SMU housing when they are returned from outlying counties.
Correctional Programming In an effort to minimize role issues between the Sheriff's Office and Cermak mental health staffs, the Sheriffs Office mental health staff discontinued their provision of group programming on the special management units in January 2016. The DOC has significantly increased the amount of enrichment programs that are offered to other detainees across the compound (see Attachment A).
'of~
DIVISION2
Inmate Hvgiene Inmates housed in Division 08 RTU continue to have access to sanitation kits, which are maintained on the living unit. The living unit showers in RTU continue to be power washed on a regular schedule to manage the soap scum. In October 2016, detainees housed in Division 08 RTU reported inconsistent access to hygiene items between weekly distributions. To minimize continued issues, Superintendent Brown informed all divisional staff that detainees housed in RTU are allowed access to hygiene supplies as needed and issued a notification to staff identifying the storage areas for the items.
The DOC continues to assist seriously mentally ill detainees housed in Cermak that consistently demonstrate an inability to complete their daily living skills through the facilitation of compassionate showers. An interagency team of DOC and nursing staff typically complete 1-2 compassionate showers monthly.
Recreation All detainees across the compound have access to recreation. Detainees housed in Cermak typically had access to indoor and outdoor recreation in the Division 4 gynmasium or yard every other week. There was difficulty in coordinating schedules across disciplines for movement

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 58 of 110 PageID #:5188
AppendixN The Agreed Order Status Update Page 27 of 55
outside of the building. Thus in October, the DOC and Cermak collaborated to reconfigure an uninhabited living unit in Cermak to a recreational space. The space includes group games (i.e., bean bag toss, plastic table tennis, plastic floor darts for wheelchair-bound detainees, etc.), board games and activities. Additionally, the agencies installed two televisions to the 2Southeast unit, an area that houses detainees with serious mental illness and histories of violence. We utilize the space to allow increased hours out of cell. Detainees that were previously allowed one hour out of cell each day due to their level of violence now typically receive 3 hours out of cell to watch television, engage with the staff and complete their hygiene. Most recently, the Cermak Superintendent and DOC staff facilitated a talent show for the detainees housed in 2South. All of the detainees were allowed out of their cell to participate and enjoy cheering on about 7 oftheir tier mate,s who sang, danced, recited history and poetry. Such activities are planned periodically. Detainees identified as seriously mentally ill and housed in RTU had access to recreation 1-2 times each week. Access to recreation in RTU is expected to increase as it was recently assigned to a correctional supervisor. The DOC has been working with our County partners to weatherize the RTU patios to allow for continued use during the winter months. We received confirmation that at least one out offour patios will be weatherized in FY2017.
November 2016 Metzner assessment: The status update section provides a comprehensive summary of the P2 and P3 levels of mental healthcare being offered in the CCDOC.
Division 2 P2 inmates were reported by custody staff to have access to the indoor recreational area on the first floor on a once per month basis and to the outdoor recreational yard 1-2 times per week. However, inmates uniformly reported during my community meeting with them during the afternoon ofNovember 16, 2016 that access to the outdoor recreational area during the past month was once every two weeks. This appeared to be confirmed by review of the custody logbook. Inmates continued to report the lack of recreational materials in the first floor indoor recreational area.
Division 2 P2 inmates had many complaints about medications they were not receiving, which were primarily non-formulary medications. Continuity of medications did not appear to be problematic except following housing moves. The scarcity of mental health progrannning was a significant complaint by these inmates. However, as compared to prior site visits, the focus of the inmates' complaints were on conditions of confmement in contrast to mental health system issues. For example, several inmates did not have access to hygiene materials such as toothbrushes and several did not have access to towels due to apparent shortages that was confirmed by custody leadership staff. Other verified issues included or access to the barber, except when going to court, and issues with being able to use their telephone cards.
tX
Information was obtained relevant to the special management unit as follows:
• Compound Census 11114116: 8,046 • Sl\1UCensus 11114116:175 (31 inRTU; 144inDivision9) • Thus, 2.2% of the detainee population are currently housed in SMU

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AppendixN The Agreed Order Status Update Page 28 of 55

o This is a reduction in the percentage ofindividuals in SMU from the last site visit. o During the last site visit (4/18/16), there were 217 individuals in the SMU tiers
and a total compound census of8318 (= 2.6% ofthe detainee population was housed in SMU) • Approximately 77% of the detainees currently in the RTU SMU have been there for less than 14 days o All detainees that have been housed in RTU SMU for longer than 14 days are identified as M3 and/or P2 • 16% of the current RTU SMU detainees are identified as P3 • Median length of stay in RTU SMU tiers is 5.7 days • On an average day, 84% of people in RTU SMU had been there for less than 14 days • On an average day, 36% of people in RTU SMU had a P3 alert at the time

The above statistics are encouraging for the following reasons:

1. The percentage of detainees housed in a SMU is low and continues to decline. 2. The percentage of P3 detainees in a SMU and their length of stays are relatively short.

RTU SMU inmates are offered two hours per day of unstructured out of cell time as compared to Division 9 SMU inmates, who were reportedly offered three hours per day ofunstructured out of cell time. The offered structured as therapeutic time was as follows:

Outpatient and SMU programming hours have been monitored as ot July ot thiS year. ., nese are snown oy area DeJow.

OUTPATIENT & SMU PROGRAMMING HOURS 2016

lOCATIONS JAN FEB MAR APR MAY JUN JUl

AUG

SEP

RTU4A RTUlMU RTU F/4P2 RTU FSA

31/32 78/90
8/8 8/8

27/32 50/74
6/8 8/8

21/"JZ 61/86
5/8 8/8

OCT NOV DEC
19/28 38/58
6/6 8/8

TOT
98/120 "12.7/308
25/30 32/32

The structured therapeutic out of cell time offered to RTU SMU inmates is significantly less than the time offered to RTU IMU inmates directly related to the more adequate mental health staffing allocations assigned to the IMU. The 10 cell IMU program has been successful in providing needed treatment to very difficult inmates, who had previously essentially been locked down in tl'le 2SE unit within Cermak. Increased staffing allocations are necessary for the RTU SMU to provide adequate treatment. During November 15,2016, there were 33 mental health caseload inmates housed in the RTU SMU and the IMU. It is recommended that a 0.25 FTE psychiatrist be allocated to cover both of these units, which are currently covered by multiple psychiatrists. A mental health unit director is needed to cover for both of these units.

I briefly observed that mental health rounding process in Unit H of Division 9 during the morning of November 17, 2016. Inmates uniformly reported that they were receiving only one hour per day of dayroom time in contrast to fue previously reported 3 hours per day. Subsequent

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Appendix IV The Agreed Order Status Update Page 29 of 55

review of custody logbooks and videotapes indicated that the amount of dayroom time being offered to these inmates varied from 1 to 3 hours per day, which was related primarily to custody staffing on the unit on a particular day in addition to other factors including on unit incidents. It was clear that they were not receiving three hours of dayroom time on a daily basis. However, the out of cell time being provided to all SMU inmates continues to be very progressive and is indicative that CCDOC is on the verge ofbeing on the cutting edge nationwide in the context of improving conditions of confinement within a SMU environment
Out of cell structured therapeutic activities for the male RTU detainees were as follows:

lOC
ON

I JAN

FEB

2.7

2.4

OFF

8.4

9.0

I·

TOT

11.1, 11.4

MALE INTERMEDIATE WEEKLY PROGRAMMING HOURS Z016

MAR 2.1 6.1

APR 2.5 6.3

MAY
I 2.3
' 6.2

JUN 3.6 4.1

JUt

AUG

2.71

3.2

3.6

3.0

SEP 3.2 3.1

8.2

8.8

8.5

7.7

6.3

6.2

6.3

! I OCT

NOV DEC

3.2 I

2.8

6.0

AVE 2.8 5.3 8.1

Cancellations of such programming was related to the following:

MENTAl HEAlTH MONTHlY STATISTICS 2016 CC+!HS
For male programming in RTU, groups were canceled, on average, 43 times per month, which clinical staff scheduling conflicts and lack of security accounting
for 26 cam:elations per month.

MALE INTERMEDIATE CANCELED PROGRAMMING HOURS 2016

REASONS REC,BARBER ClfN STF CONFL CUNICAl MTGS LACK S!ECURITY
SEARCHES FIGHTS, UOF
?TREFUSALS ENVTI.ISSUES
I' TOTAL

JAN 16 8 4 4
32

! FEB MAR APR MAY j JUN

!Ul AUG

'

6 l 18

11

Z7

9. 9

Z1

4

13

6

5

6

13

4

13

6

5

2

9 15

10

4

10

2

3

3

1 2

22

60 34

33

18 4

" 20 4

4 I

4

2 '

3

I

79

46 43

SEP 7 6 18
31

OCT NOV DEC s
13 3
16 13
50

TOT 53
137
.52
125
13 11
430

Similar statistics for the female RTU were as follows:

FEMALE INTERMEDIATE MENTAL HEALTH PROGRAMMING HOURS IN RTU

female programming hours in RTU have also moved in the direction of'off-tier' group programming in accordance with departmental goals, and have
maintained a proportion similar to that of male programming for 2016. In addition, canceled group hours have averaged 9.1 per months during this period. As in the case of male programming in RTU, decreases in programming hours have been ilttributable to a developing staff shortage during this period.

LOC ON OFF
TOT

JAN 5.3 5.2
11.5

FEB 4.8 5.7
10.5

MAR 3.0 7.2 10.2

FEMALE JNTE:RMEDIATE WEEKLY PROGRAMMING HOURS 2016

APR 2.5 5.3

MAY
4.7
s.s

JUIV 4.3 5.7

JUL 1.2 4.5

AUG 0.3 4.S

SEP 0.3 4.3

8.8

10.2

10.0

5.7

4.8

4.5

ocr

NOV

0.5 4.7

5.2

DEC

AVE

2.7

5.5

8.2

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AppendixN The Agreed Order Status Update Page 30 of 55

FEMALE INTERMEDIATE CANCELED PROGRAMMING HOURS 2016

REASONS

JAN FEB MAR APR MAY JUN

JUL AUG SEP OCT NOV DEC

REC, BARBER

2

1

CLIN STF CONFL

1

6

3

3

14 I

12

7

2

4

1

CLINICAL MTGS

1

2

2

2

2

2

2

2

LACK SECURITY

2

SEARCHES

1

FIGHTS, UOF

1

1

NOOOCU

8

4

1

ENVTL ISSUES

3

1

1

TOTAL

5

9

5 5 16

15

10

14

12

3

TOT 3
53 15
2 1 2 13 5 94

As evidenced in the above tables, the two major barriers for achieving compliance with the number of hours per week of out of cell structured therapeutic activities for RTU male detainees are mental health clinical staffing issues (i.e., vacancies and/or staffing allocations) and correctional staff use of resources. It is expected that the latter issue will be resolved in the very near future.
The major barrier for achieving compliance with the number ofhours per week of out of cell structured therapeutic activities for RTU female detainees is mental health clinical staffing issues (i.e., vacancies and/or staffing allocations).
Male RTU inmates were reported to have access to the outdoor patio area on a twice per week basis (1 hour each time) as compared to the female RTU inmates' access of3 to 4 times per week. However, inmates continued to report very limited access to the outdoor patio areas. Plans are being made to winterize one of the outdoor patio areas.
As stated in the status update section:
B.ed space remains a significant issue for P3 males. Although an overflow dorm was created on the second floor ofRTU (2B), this housing is shared with medical patients and is not sufficient for the number of P3 males awaiting a space on the fourth floor. Consequently, the number of detainees placed on 2B and other tiers within RTU typically varies beween 20 to 40 detainees. In addition, Division 102B has opened an overflow dorm for P3 males, which also houses anywhere between 15 to 20 detainees.
P3 inmates in Division 10 has an average length of stay of 60 days in Division 10. They are only offered two therapeutic groups per week.

The current RTU staffing allocations were as follows:

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Appendix rv
The Agreed Order Status Update Page 31 of 55

Psychiatrist Psychologist/Unit Director Social workers
Mental Health Specialists (cover RTU5th floor and Div. 4 for female services) Population

RTU 5th floor females
1.2 1.0
1.5+ 1.0 Expressive therapist 3 MHS III in am 2MHS III+ 2 MHS IT
rnprn
P3 84 P2 137 ( 221)

RTU 4th floor(+ 2nd and 3ro floors) 1.6+0.2 ( PA)=1.8 1.0
1.5+1.0 Expressive therapist 3 MHS III + 3 MHS IIonAM 4 MHS III's on PM
P3 317 P2 99 (416)

RTU total population 637; P2- 236; P3- 401

In addition to the mental health specialists' vacancies and/or allocation issues that negatively impact p);oviding adequate access to inmates for out of cell structured therapeutic activities, the allocations ofpsychiatrists' positions to the RTU are not sufficient. Currently-2.0 FTE psychiatrists provide services to a residential treatment level of care population of 401 inmates and 1.0 FTE psychiatrist provides mental health services to an outpatient population of236 P2 inmates housed in the RTU. On average, 415 inmates have had a P3 designation on any given day during the past 11 months. In general, 1.0 FTE psychiatrist position is needed for 80- 100 RTU level ofmental health care inmates.

The average daily census of inmates with a P2 designation throughout CCDOC during the past 11 months has been 1605 with an average of -180 inmates per day in the SMU and 502 inmates per day with a maximum custody level in Division 10. I have significant concerns re: the current allocation of psychiatrists' positions for inmates requiring a P2 level ofmental healthcare. The psychiatric staffing allocations for general population medium or minimum custody level P2 inmates will be less than the allocation required for higher security P2 inmates due to access issues. I discussed at length my concerns and recommendations with mental healthcare leadership staff, who agreed to submit to me a draft by January 1, 2017 re: a staffing needs analysis that may include relevant QI studies and/or management reports.

Information was obtained from line psychiatrists regarding the amount of time allotted to initial psychiatric examinations. They reported that the amount oftime required for such examinations, which included review of relevant records, clinical interview, documentation and waiting time for the inmate to arrive for the examination generally required a total20-45 minutes. Psychologists indicated that their initial comprehensive mental health assessments generally involved 30 to 60 minutes in duration.

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Appendix IV The Agreed Order Status Update Page 32 of 55

I reviewed three initial psychiatric evaluations that were selected on a random basis. These evaluations were not adequate based on documentation, which lacked support for the diagnosis and/or a reasonable review of systems specific to the inmates' presenting complaint and/or reason for referral. Psychosocial history, family history and substance abuse history were poorly documented. In addition, the planned follow-up for inmates initially started on psychotropic medications was not timely (generally 8-12 weeks). Discharge planning was not addressed,
was which problematic because two of the inmates were discharged prior to the planned
psychiatric follow-up. These issues appeared to be related to large caseloads and limited time available for such assessments.

Recommendations:

1. Address the staffing vacancy and or allocation issues as summarized above, along with a staffing needs analysis as previously referenced.

2. More RTU beds are needed as evidenced by the P3 overflow units.

3. Various conditions of confinement, such as access to basic hygiene items, towels, outdoor recreation, etc. need to be more closely monitored, and remedied when needed, by custody staff

e.

Cermak shall ensure that treatment plans adequately address inmates'

serious mental health needs and that the plans contain interventions specifically

tailored to the inmates' diagnoses.

Compliance Assessment: Partial compliance

Factual Findings:

November 2016 Cermak Status Update

Please see Appendix for Treatment Plan QI Audits for each level of care.

The Unit;Director for the Intensive Management Unit (IMU) in consultation with the Chief Psychiatrist developed a behavioral custody report that is submitted to the courts upon successful completion ofthe IMU program. Please see Appendix for a sample of report.

Additionally, comprehensive Interagency Behavioral Management Plans continue to be developed as needed by Unit Directors in concert the Chief Psychologist, the Chief Psychiatrist, and the full multidisciplinary team for more complex or difficult cases. The majority of interagency plans continue to be generated in PSCU, followed by the RTU.

New proposed language for policy G.04.1 (redlined version) was forwarded to Dr. Metzner for

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Hi
AppendixN The Agreed Order Status Update Page 33 of 55
reVIew.
• P4 (Psychiatric Special Care Units): Psychiatric Special Care Units patients will have completed treatment plans within 72 of admission to the Psychiatric Special Care Unit (PSCU) by QMHP and the Treatment Team with a review and update triggered by changes in acuity (such as placement in therapeutic restraints or administration of emergency medications) and failure to achieve goals, but no less frequently than weeldy.
Once patients within PSCU's are determined to require subacute level of care, with regard to the frequency ofTreatment Plan reviews, they will have their Plans reviewed by QMHP and the Treatment Team every 30 days for two months. After that, patients within PSCU's requiring chronic level of care will have their treatment plans reviewed no less frequently then every 90 days by QMHP and the Treatment Team from that point forward.
• P3(Intermediate Care): Mental Health Intermediate/residential level of care patients will have completed treatment plans by a QMHP within 30 days of admission, with review and update at least every 90 days thereafter.
• P2(0utpatient Care): Mental Health Outpatient level of care patients will have completed treatment plans by a QMHP within 45 days of admission, with review and update at least annl.lftlly thereafter.
November 2016 Metzner Assessment: As per status update section. Results of the Treatment Plan QI Audits for each level of care were summarized as follows:
Executive Summary The database of special care patients was reviewed for compliance with the treatment plan policy. Thirty patient charts were selected at random representing patients housed in various units within Cermak (acute care, chronic care, medical). 93% of charts reviewed had P4 ordered within 72 hours of admission to PSCU. Of the 30 treatment plans reviewed, 28 reflected multidisciplinary representation at MDT, 28 included psychiatry in all P4 and P3 plan development, 28 of the treatment plans were completed by a QMHP, and in 15 cases it was documented that the patient was informed of the plan. PSCU plans will continue to be completed by a QMHP and involving the patient (either by being present during plan development or by informing the patient ofthe plan) will be increased. Treatment plan updates continue to be an area for improvement. 45% ofP4 Acute plans were updated within 7 days. 100% ofP4 Chronic plans were updated within 90 days. QMHP will improve the consistency with which treatment plans for Acute patients are developed/reviewed/updated. P4 patients will be classified as high, medium, or low with regards to acuity and treatment plans will be reviewed/updated according to the corresponding level of care (every 7 days for high, every 30 days for medium, every 90 days for low). Staff

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Appendix fV The Agreed Order Status Update Page 34 of 55
will be trained on these expectations and supervisors will regularly monitor compliance.
The overall percentage of compliance measured by the Cermak Treatment Plan Audit Tool was 81% (average of all quality indicators). This increased from 68% when the treatment plans were first audited in April2016.
Significant improvement is noted.
Reco~endations: Repeat the QI following the planned training.
f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates' serious mental health needs and ensure that psychiatrists see inmates in a timely manner.
Compliance Assessment: Compliance (11116)
Factual Findings:
April 2016 Metzner assessment: My November 2015 report included the following:
The recently approved salary increase and the Shakman pilot hiring project summarized in the current status section are very positive signs and should significantly assist in recruiting psychiatrists.
During April2016 there were 11.2 PTE psychiatrists' positions filled (which represented a loss of 0.5 PTE psychiatrists as compared to the last site visit) and 5.0 PTE psychologist positions filled (which represented a loss of 1.0 PTE psychologist position). The total mental health staff vacancy rate has decreased somewhat to 15% since the last site assessment.
I also strongly support the creation of the proposed Associate Chair of Psychiatry, Director of Infirmary Psychiatry position.
November 2016 Cermak Status Update
See Attachments B & C.
Novem~r 2016 Metzner Assessment: As summarized earlier in this report, psychiatrists are now meeting time for frames relevant to emergent, urgent, and routine referrals. Related to salary increases, streamlining of the hiring process, success of the Shakman pilot hiring project and an aggressive recruitment process there have been no functional vacancies relevant to the 14.9 PTE allocated psychiatrists' positions since August 2016.

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AppendixN The Agreed Order Status Update Page35of55
As was summarized in provision 59 d., I think it is very likely that the total funded psychiatrists' allocations are not sufficient to meet the inmates' serious mental health needs. However, for reasons discussed in that provision, mental health leadership staffwill work with me to jointly develop a needs assessment relevant to this issue by January 1, 2017. Compliance is found because all of the current funded psychiatrists' positions are functionally filled. I will reassess this provision during the next site visit in the context ofthe plan need assessments and subsequent assessment specific to provision 59 d.
Recommendations:
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defming the various levels of care and identifying the space, staffmg, and programming that are appropriate to each identified level of care.
Compllianc,e Assessment: Partial compliance
Factual Findings:
April2016 Metzner assessment: A staffing proposal is in the process ofbeing submitted that will include a request for additional mental health staffwith an emphasis on additional licensed mental health specialist positions. Although it is clear that additional psychiatry and psychology staff are needed the emphasis will be on the mental health specialist positions due to the issues involved'with the current psychologists' and psychiatrist' vacancies. The need for more licensed mental health specialists is particularly acute within the RTU as evidenced in the sections relevant to treatment plans and services being provided to RTU inmates who have a protective custody status.
The problems associated with the significant vacancies relevant to psychiatrists and psychologists impact inmates access to care and quality of care issues. It is clear that there has been a direct correlation with a significant decrease in the total mental health staffvacancy rate and significant improvement in the quality of care offered to inmates.
Recommendations: I agree that the emphasis should be placed on the mental health specialist positions for the reason summarized above.
November 2016 Cermak Status Update
Please see Update in 59f. Also see PDF Appendix.

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Appendix IV The Agreed Order Status Update Page 36 of 55
November 2016 Metzner Assessment: Refer to Attachments B & C for staffing allocations and vacancies. It is very encouraging that 14.0 FTE additional mental health specialists' allocations was just recently funded. Refer to provision h regarding the planned needs assessment. This needs assessment will help determine whether the staffing issues identified in provision 59 d. are due to vacancy issues, performance issues and/or staff allocation issues.
Recommendations: Complete the staffing needs analysis.
h. Inmates shall have access to appropriate inf"Irmary psychiatric care when clinically appropriate.
Compliance Assessment: Compliance (11/16)
Factual;Findings:
April 20ll6 Recommendations: The number of out of cell structured therapeutic activities and out of cell unstructured time on all of these units needs to be increased and monitored.
November 2016 Cermak Status Update
Cermak Male Acute, Subacute and Chronic Mental Health Unit Descriptions The Cermak male psychiatric llllits are comprised of 60 beds distributed among 3 units- 2North (acute llllit), 2South (subacute unit) and 2East (chronic unit). The purpose of the units is to provide extended observation, stabilization and structured/unstructured therapeutic activities. Services are provided by a multidisciplinary team, which includes psychology, psychiatry, mental health specialists, nursing, social workers, correctional rehabilitation workers and custody staff.
Male detainees may be admitted to 2North, the 24-bed acute psychiatric unit, from intake, general population or other mental health units. Primary reasons for admission include an acute risk for harm to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for victimization in other living units. Detainees housed on 2North are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2North for a brief period of time before transitioning to a less restrictive setting.
The subacute mental health llllit, 2South, is a 26-bed unit for detainees that have demonstrated a decrease in the severity of psychiatric symptoms but continue to evidence symptoms that cannot safely and adequately be treated in a division with mental health services. Some detainees exhibit chronically severe symptoms that necessitate long term sheltered housing. They may be housed on 2South or 2East, a 12-bed unit that houses detainees that demonstrate severe negative symptoms ofpsychosis, chronically severe depression and/or significant cognitive delays.
Discharge Planning

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Appendix IV The Agreed Order Status Update Page37of55
Cermak male mental health units are staffed with 1 Medical Social Worker who maintains regular cpntact with detainees diagnosed with serious mental illness to coordinate post-release treatment services in the community. Due to the severity of their mental illness, all detainees released to lthe community from these units must be assessed by a Qualified Mental Health Professional prior to discharge to determine the need for hospitalization. If community hospitalization is not warranted based on the clinical assessment, the Medical Social Worker can assist the detainee with referrals to community agencies for continued treatment and shelters for housing. The Medical Social Worker can also arrange for the detainee to be given an e-script for 30 days of medication in the community as a bridge until their next provider appointment.
Cermak Female Acute and Chronic Mental Health Unit Description
The Cermak female acute and chronic mental health unit, 2West, is a 20-bed unit devoted to the psychiatric stabilization of detainees whose presentation warrant stabilization and/or extended observation. Detainees may be admitted to 2West from intake, general population or other mental health units. Primary reasons for admission include an acute risk for harm to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for vietimization in other living units. Detainees housed on 2West are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2West for a brief period of time before transitioning to a less restrictive setting unless they present with symptoms that warrant chronic care services. Chronically mentally ill detainees that require continued housing on 2West demonstrate severe negative symptoms ofpsychosis, chronically severe depression and/or significant cognitive delays that cannot safely and adequately be treated in a division with mental health services.
Discharge Planning
The Cermak female mental health unit is staffed with 1 Medical Social Worker who maintains regular cgntact with detainees diagnosed with serious mental illness to coordinate post-release treatment services in the community. Due to the severity of their mental illness, all detainees released to the community from this unit must be assessed by a Qualified Mental Health Professional prior to discharge to determine the need for hospitalization. If community hospitalization is not warranted based on the clinical assessment, the Medical Social Worker can assist the detainee with referrals to community agencies for continued treatment and shelters for housing. The Medical Social Worker can also arrange for the detainee to be given a prescription for discharge medications.
Psychiatric coverage of the Psychiatric Special Care Units has been strengthened: 2N is covered by 3 Psychiatrists and 1 Psychiatric PA (Balawender). Dr. Bednarz and Haq joined Dr. Paschos on the PSCU team in May 2016 and October 2016 respectively. They also have clinical assignments outside of the PSCU setting. 2W covered by Dr. Howard. 2S/2SE is covered by Drs. Howard and Bednarz. 2E is covered by Dr. Moreno. Please see PDF Appendix for QI related to frequency of contact ofPSCU patients.

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2 North: 3 Psychiatrist+1 PA with 7-day Coverage-2.4 FTE 2 South/Southeast: 2 Psychiatrist with 5-day Coverage-0.6 FTE 2 West: 1 psychiatrist with 7 day coverage-0.8 FTE 2 E: 1 Psychiatrist Once a month coverage-O.lFTE
Treatment Compliance Incentive Program has also positively impacted the overall milieu Dr. Waxler (Unit Director for 2N/2W) continues to provide supervision to staff. Dr. Nunez provides supervision to staff on 2S/2E.
Upon request from Cermak Mental Health Leadership, the DOC continues to supply snack items to be used for incentives for treatment compliance.
According to the Interagency PSCU Policy, bed assignment is a collaborative task between DOC, Nursing, and Mental Health. Striving to maintain the integrity of ongoing out of cell structured therapeutic programming and recognizing the importance ofhaving dayroom available for therapeutic programming, Cermak supports using every appropriate space/accommodation
., for patients in need of single rooms, including, but not limited to:
• Temporarily holding 2N detainees on 2S and 2E. When there is a new admission(more unstable) to 2N in need of a single room, more stable 2N patients occupying a single room may be transferred to 2S and 2E on a temporary basis.
• Using existing single rooms on 2N (putting new detainees in need of single room in the rooms of established (stable) single room patients who are having their "hour" out).
• Using group rooms (when group room detainees are out for therapeutic and unstructured activities) to temporarily insert new admissions in.
• Temporarily keeping new detainees in other appropriate clinical/non clinical space on 2N (for instance, the long hallway and the small group room). DOC is requested to provide direct observation of these detainees if they are kept in clinical areas.
• Keeping new detainees who need a single room in the big dayroom will be used only as the last resort.
Providers, Unit Directors, and MHS will collaborate with DOC Supervisors and front line staff identifying accommodations designed to avoid any disruption in therapeutic programming
2S/2SE concentrates the most recalcitrant and treatment refractory detainees with serious mental illness on the compound. In order to preserve a safe, sanitary, and therapeutic milieu in the area where adherence to hygiene and personal self care is oftentimes a challenge for many of those detainees, Cermak MH, Environmental Services, and DOC staff collaborate in maintaining:
1. Cleaning schedule- twice a day (am and pm) including the weekends on both 2S and 2SE. The pm cleaning is for selected cells that need extra attention. Power washing

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frequency is to be determined. Supt. Hays is asked to provide staff to assist the cleaning of2S/2SE. 2. Additionally, DFM Plumbing foreman have been requested to have a plumber come to 2S/2SE every morning Monday through Friday. 3. Environmental inspection detected no present mold contaminated surfaces on vinyl ,~hairs in the dayroom and nurses' station. 4. ·One ceiling tile with mold has been replaced
5. AIC issues have been corrected.
6. The fruit flies infestation has been reduced. DOC will avoid, if possible, feeding detainees in their cells, when practicable, in order to minimize the resurgence of fruit flies' population.
7. "Humanitarian showers" on the 3-llPm shift will be available as needed in close coordination between DOC, PCS, MHS, and Psychiatry. MH will submit the lists of detainees requiring hygiene to Supt. Hayes and Shift Commanders. MH will secure OT, if need be, to assist in coordinated preplanned hygiene.
8. Cleaning and environmental maintenance should not interfere with ongoing out of cell therapeutic programming.
Updates: PSCU 2N (males) and 2W (females) are the Psychiatric Special Care Units within Cermak Health Services that provide psychiatric/mental health services to a population of acute, sub-acute, and chronic individuals. A psychiatrist meets with each patient within 24-hours of admission and then daily thereafter. Structured group programming is delivered daily to patients, which ranges from a "Rise and Shine" group focusing on hygiene/ADLs, to "Community Meeting/Unit Orientation," as well as more clinically focused groups.
Programmling Clinical groups take place both in the day room and in the small group room and generally engage patients in discussing topics such as Anger Management, Coping Skills, Patient Rights, Understanding Mental illness, etc. Dayroom hours and structured programming are calculated most closdy on the 2 North Unit. Through an interagency directive, both dayroom hours and programming hours have been increased on 2 North and 2 West. Patients housed on the Special Care Units are seen by a Mental Health Specialist during rounds on each shift, and they have access t6' a licensed Mental Health Specialist 24 hours a day. Mental health staff engages patients either in their room or in the milieu (dayroom or interview room). Patients also have access to psychiatric services while housed on the Special Care Unit. They typically meet with a psychiatrist or physician's assistant daily.
Because 2 North calculates both daily programming hours and dayroom hours, the following data was derived from 2 North. The dayroom hours have increased beginning in May 2016 from an average of5.9 hours per day (January-April) to an average of7.9 hours per day (MaySeptember). This increase of access to care has allowed for an increase of mental health programming from an average of 4.8 hours per day (January- April) to an average of 6.5 hours

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per day (May-September).
Since May 2016, patients on 2N have been receiving an average of 6.5 hours of structured group progranuning per day; while patients on 2W have been receiving an average of41.04 hours of structured group therapy per week, per patient. These numbers are quite high when patient access is considered. There are many factors that negatively impact the access mental health specialists have to work with patients. For 2N, patients are being engaged in structured group programming an average of82% of the time they are out of their room over the last five months (May 2016September 2016).
The percentage of large group room therapy versus small group room therapy has decreased slightly over the past five months. The majority of small group room therapy has been expressive art therapy groups where patients have the opportunity to listen to music of their choosing, write letters with a provided stamped envelope, create art with markers, write poetry, and look up words in a dictionary. The expressive arts therapist assigned to the second floor of Cermak has been given additional responsibilities one day a week which has taken his ability to provide a "floating day" which traditionally allowed him to make up for services that were cancelled due to holidays, unit closures, etc. Approximately 95% of group programming takes place in the large group room. We will be working towards increasing small group room programming by 23 hours/week by assigning each mental health specialist to conduct one small room group session per week;
An ongoing challenge to providing groups in the small group room is difficulty with obtaining proper CCDOC supervision. In order to run these groups, a secure environment must be maintained by having a proximate officer. This is not always possible in such a dynamic environment where there are conflicting activities to supervise, which include medication pass, psychiatry evaluations, crisis interventions, and movement off unit. Staffis working towards increasing the amount of small group room therapy provided each month by collaborating with CCDOC partners in order to have the groups properly supervised.
The unit schedules aspire to provide 12 hours of open dayroom time each day where patients have access to care and are provided with 8 hours of structured programming. The newly disseminated interagency unit schedule is attached in the PDF Appendix). Although the schedule provides 6 hours of dayroom time in during the 7-3 shift and another 6 hours during the 3-11 shift, the highest daily average of dayroom hours for a month was just under 10 hours/day (June 20 16). There are several factors that can impact the availability of dayroom time. The most frequent reason over the past six months has been for the challenge of detainees requiring single cells versus the number of single cell housing available in the PSCU. Once admitted patients are often housed in the dayroom for several hours which precludes other patients from utilizing the dayroom area. As a result, structured group programming can be interrupted, delayed, or cancelled. For example, the month of August had a total of 12 shifts in which structured programming was either postponed or cancelled due to "patients housed in the dayroom."

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Several approaches/solutions have been proposed to prevent dayroom closure including: 1) placing a newly admitted patient who requires a single cell in a room while group takes place and then after the dayroom hours return the patient to the dayroom, 2) situating the patient in the back hallway with security supervision, and 3) boarding more stable patients on other second floor units if there is available space.
A QI study was initiated in May 2016 to ensure that dayroom hours are being accurately tracked, but the results ofthis study are limited. The data comparing the reported dayroom hours from mental health specialists with CCDOC video is attached to this document (PDF Appendix). We will needJto continue to closely monitor dayroom access as it is directly related to group prograrnmmg.
Treatment Planning An area of improvement that was identified during the last audit was treatment plan development, review, and update. Procedures have been initiated on both 2 North and 2 West to ensure that treatment plans are updated within the specified timeframes of our policies. The attached treatment plan audit will describe improvements in this area over the last five months. Once consistency is achieved with the review and update of treatment plans, the quality and effectiveness of the treatment plan should be assessed. Outcome studies may help to better understand the impact our services have on our patients' mental health and wellbeing. The treatment plan audit and summary is provided in the PDF Appendix.
Additional Activities In addition to providing assessment/treatment planning, milieu therapy, rounds, individual sessions, and group sessions, the mental health staff also meets daily in a "morning huddle" to discuss new admissions and any concerns or questions from the previous day(s). Staff will also regularly engage in multidisciplinary treatment team meetings held twice a week on both units to discuss patient progress, update the patients' treatment plan, and address any other pertinent items/issues. The restraint and seclusion log for the previous week is reviewed twice weekly (am and pm shifts) at staffing, and staff is given the opportunity to discuss any issues or questions they have with the process ofutilizing therapeutic restraint/seclusion. Multidisciplinary Treatment Team (MDT) meetings are scheduled regularly and consist of psychiatrists, psychologists, physician's assistants, mental health specialists, nurses, and correctional officers. With regards to the milieu and therapeutic environment on the psychiatric special care units, staff work towards developing rapport with each patient and providing a sense ofphysical and emotional safety. This is especially the case on 2 West (females), where staff provides a more trauma-irlformed approach to working with patients. Staff encourages patient compliance with treatment while also respecting patients' rights. Mental health staff spends time describing patient rights with regards to medical/mental health treatments.
The incentive program is utilized on 2 West to encourage patients to participate in healthpromoting activities, such as hygiene, group therapy, and medication compliance. Mental health stafftallies points and provides incentives for patients who engage in these activities. Mental

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health staff will modifY the incentive program for patients with special circumstances (such as out alone/house alone status) to make it possible for all patients to participate in the program. An area that has been improving is cooperation/collaboration across disciplines. This has traditionally been a challenge, but has been moving in a positive direction. Mental health specialists are more likely to communicate/collaborate with medical, nursing, and the officers. This collaboration can be challenging at times due to discrepancies between professional perspectives and opinions, but has been improving. The increased collaboration amongst leadership may be driving this improvement (i.e. regular interagency management meeting and multidisciplinary staffing). We will continue to hold multidisciplinary clinical staffings to ensure that all disciplines are represented and that all varying perspectives are taken into account.
Areas for Improvement
The key areas identified for improvement are:
1. Monitor dayroom closures more closely and develop interagency procedures to minimize dayroom closures
2. Increase small group room programming by scheduling one small group per clinician per week
3. Continue to encourage full multidisciplinary participation at clinical staffings
4. Continue to monitor compliance with treatment plan policy
Detaine~ meeting criteria for involuntary admission by petition and certificate are transported to one of~o area hospitals (Mt. Sinai and St. Anthony) upon release from Cermak by the court system. All detainees with P4 alert (and some with P3 alerts) are evaluated by Mental Health Staff at the moment of court release, and those anticipated to meet criteria for involuntary admission in the community are also 'flagged' ahead of time in EMR to ensure that their need for continued inpatient treatment is not overlooked if they are released in the overnight hours. There has been no indication of 'missed' evaluations at discharge recently, and the program continues to be very efficient. The numbers of involuntarily hospitalized patients continue to be relatively stable in spite of overall reduction in jail census.
Cermak Male Sub-Acute and Chronic Mental Health Units Description
The Cermak male sub-acute mental health unit, 2 South, is a 26-bed unit devoted to psychiatric stabilization and maintenance of detainees suffering from severe psychiatric illness whose condition warrants weeks or months of extended inpatient care. Detainees are transferred to 2 South from 2 North, the acute care and triage unit. Primary reasons for transfer are severity of illness or symptom presentation, inability to achieve successful adjustment at a lower level of care, treatment refusal and need for emergency involuntary medication or nonemergency medication by court order, pending forensic evaluation for Fitness to Stand Trial (BCX), or

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finding of Unfit to Stand Trial (UST) with pending transfer to a forensic state psychiatric facility for fitness restoration. The table below sunnnarizes the status of2 South patients on November 7, 2016.

STATUS OF 2 SOUTH PTS*

STATUS

#PTS INVMEDS !NV ORDERED MEDS PENDING

UST

7

2

0

BCX 11

3

0

NOBCX

8

1

2

TOTAL 26

6

2

*on 11107116

Many 2 S"outh patients are at acute risk for harm to self or others, are unable to care for self, or suffer marked decompensation which could create vulnerability in less intensive levels of care. Patients housed on 2 South see a psychiatrist a minimum of once a week, and have twenty or more hours of mental health progrannning during that period. All 2 South patients are considered for linkage planning and community reintegration services provided they are to be released to the community. A number of patients are petitioned and certified for involuntary admission to area psychiatric hospitals when released by the court.

2 East is a 12-bed chronic care unit adjacent to 2 South. It houses patients who are not expected to be able to adjust successfully elsewhere in the jail, and many of these detainees are considered clinically frail and susceptible to exploitation. Patients housed on 2 East see a psychiatrist a minimum of once a month, and share the other services found on 2 South.

Significant progress has been made relevant to the use of involuntary administration of psychotropic medications on a nonemergency basis, which is well sunnnarized in Attachment D. The need to initiate civil commitment procedures at the time of discharge from CCDOC has decreased, which is likely a reflection of improve mental health services being offered within Division 8 (see Attachment D).

CCSO facilitated sessions of Crisis Intervention Training (CIT) training for Cermak clinical staff and custody staff. Staff persons selected for this initial training are currently assigned to the psychiatric care units or the residential treatment unit. Staff selected to attend reported finding the training extremely useful. There have been 4 full40 hour classes and 1 one day training. Cermak's involvement is as follows:

13 unique staff completed the 1 day training (3 of those individuals are no longer with us). 17 unique staff completed the full40 hour training (1 of those individuals is no longer with us).
·t~
DOC Administration initiated multidisciplinary Crisis Intervention Training (CIT) in November 2015. The initial training consisted of a one-day introductory course. Thirty staff members from

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Cermak and the DOC completed the 8-hour CIT course. Subsequent training consisted of a 40hour CUJ!liiculum. To date, 120 DOC and Cermak employees have completed the 40-hour CIT course.
Staff safety checklist was developed in MH CQI committee meetings and shared with CCDOC and Cermak Leadership (please see PDF Appendix). Findings are further discussed in CQI Suicide Prevention Committee meeting and the MH CQI meeting. Concerns voiced by front line staff were incorporated in the discussion and relayed to CCDOC Leadership. A checklist of safety issues (some of them impacting delivery of services, including, but not limited to crisis services and therapeutic progrannning in segregation) to be addressed in clinical areas was generated and can be found in the Appendix. Medical and Mental Health Staff are encouraged to provide real time incident reporting to enhance the timeliness of communications with CCDOC; creation ofthe " Staff Safety Incident Report", as a supplement to the EMERS report ( June 2016).
The Medical Social Workers also continue to be an integral part ofthe response to calls received by the Sheriff's Care Line. All information related to mental health issues continues to be forwarded to the identified medical social workers for follow up and/or delegation to divisional social workers if indicated. Since the last visit, our social work staffhas addressed 75 calls/refetrals. Of those referrals, (71 %) had already been identified, evaluated, placed on the MH caseload and were receiving treatment. (21 %) of the referrals yielded new additions to the MH caseload or yielded information that Cermak providers did not yet have access to, and the remaining (8%) referrals were determined to not be in need of continued follow up from the MH department. This collaborative community outreach effort has resulted in increased access to collateral information and opportunity for improved care and clarification ofneeds.
November 2016 Metzner assessment:
Attachm~nt E provides statistics relevant to admissions, discharges and average length of stay within the second floor mental health units.
Progrannning hours on the second floor mental health units were as follows:
INPATIENT MENTAL HEALTH PROGRAMMING HOURS
On the inpatient side, programming hours have dim bed steadily over the course of 2016. On 2 North, where programming hours are calculated on a daily rather than w,eekly basis owing to the brief stays patients have there, hours have increased from 4.9 per day in January to 73 hours in October. The other inpatient ur'lit> c<~lculate programming in weekly hours. On 2 South, the average has climbed from 18.9 nours per week in January to 29.7 hours per week ln October. On 2 East, programming has increased from 15.3 to 25.3 hours per week. On 2 West, programming hours have climbed from 25.4 to 41.7 over the same period. Because of staffing shortages over the course of this year, 2 East has been designate<:! as the unit where staff can be pulled to other higher priority service areas ln Cermak when needed. Out--of-cell hours per day on 2 North have increased from 5.9 per day on average for January to 8.5 in October.

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LDC JAN FEB 2N* 4.9* 5.1*
25 18.9 20.1
ZE 15.3 18.2 2W 25.2 22.5

INPATIENT WEEKI. Y PROGRAMMING HOURS BY UNIT 2016 *2N CALCULATED BY DA \'; OTHERS BY WEEK
MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
4.4* 4.9* 6.7" 7.8* 5.8* 5.0* 6.3* 7.3* 19.6 21.6 27.6 32.2 28.5 19.6 26.8 29.7 17.4 23.8 24.6 23.2 21.1 14.8 24.5 25.3 23.6 33.5 41.6 38.2 39.8 4(i.9 44.7 41.7

AVE 5.9* 24.1 20.8 35.2

The out of cell programming offered to inmates within the inpatient mental health units continues to improve. Significant improvement has occurred on the 2S/SE units related to both the implementation of the IMU and using a door to separate the unit into two units that has allowed for increased out of cell time for inmates in both units. Television sets have also been installed in the 2SE hallways. 2W inmates' access to the dayrooms during the afternoon continues to be problematic related to the presence of"walk-alone" designated inmates. It is my understanding that a remedy for this issue into West will be implemented similar to the remedy that was implemented on the 2S/SE units.
A very reasonable process has been implemented relevant to the administration of involuntary psychotropic medications on a nonemergency basis that is largely the reflection of administrative skill and work demonstrated by David Kelner, MD.
The staffing allocations to the inpatient unit includes 3.9 FTE psychiatrists since August 2016. As a result, psychiatric staffing has been adequate. This will be problematic during staff absences due to lack of a built in relief factor.
During the site visit, I observed progranuning and out of cell time on all the units, which was consistent with the data previously sunnnarized. I also talked with inmates in group settings, who generally had very positive comments regarding the treatment program. Information obtained from these inmates was consistent with the information sunnnarized in the status update section.
It is a significant achievement that the elements of this provision are now in compliance, which is directly related to the adequate psychiatrists' staffing, diligent work by the mental health specialists and nursing staff and the good working relationship between healthcare and custody staffs. It is particularly encouraging that the custody staffhave facilitated increased out of cell time for the inmates.
Recommendations:
I am in agreement with the key areas identified for improvement, which are sunnnarized in the update section as follows:
1. Monitor dayroom closures more closely and develop interagency procedures to minimize

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dayroom closures.

2. Increase small group room programming by scheduling one small group per clinician per week.
I 3. Continue to encourage full multidisciplinary participation at clinical staffings.

4. Continue to monitor compliance with treatment plan policy Maintaining adequate staffing allocations it is also recommended.

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with the mental health caseload roster listing the

inmates currently receiving mental health care. (included in this appendix for

formatting purposes only)

Assessment: Substantial compliance (since June 2012)

j. When CCDOC alerts Cermak that an inmate is placed in lock down statns for disciplinary reasons, a Qualifiecll Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health statns.

Assessmenlt: Substantial compliance continues (since October 2012). (included in this appendix for formatting purposes only)

Factnal Findings:

November 2016 Cermak Statns Update

Disciplinary Unit continues to adhere to the following framework: if mitigating factors are identified and there is no contraindication for continued placement in disciplinary segregation they will limit disciplinary segregation time for P3 and P4 detainees to 14 days or less. Combined huddle meeting for Special Management Units takes place on a weekly basis. It was decided that these discussions are to occur at the Leadership Level/ Cermak MH Administration level and not during local divisional management meetings. Please see PDF Appendix for Mitigation Report.

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CCDOC- TOTAL INMATE DISCIPLINARY REPORTS WRITTEN

JUNE 1' 2016 TO SEPT 30'2016

DIVISION1

375

DIVISION2

678

DIVISION3

9

DIVISION 3 ANNEX

131

DIVISION 4

98

DIVISION6

657

DIVISION 8 CERMAK

230

DIVISION 8 RTU

318

DIVISION9

1,880

DIVISION10

708

DIVISION 11

504

TOTAL REPORTS

5,588

In April 2016, the DOC piloted a revised procedure for restrictive housing in Division 9 to allow detainees in restrictive housing to have 1.5 hours out of cell each day. In May 2016, the DOC transferred all general population restrictive housing units to Division 9 and initiated our Special Management Unit (SMU) housing. SMU Tiers replaced disciplinary segregation and allowed detainees to receive at least 3 hours out of cell. All detainees are secured using a waist restraint system or security cuffs and are monitored by an increased number of Officers who engage with the detainees on the tier. General population SMU tiers are staffed with at least 3 Officers and mental health SMU tiers are staffed with at least 2 Officers because the census is lower. All tiers, with the exception of Division 9-1F, allow for at least 2 detainees to interact in the dayroom at a time. Division 9 Tier IF houses detainees that are deemed the most violent based on their recent incidents. The census remains low to allow for increased engagement between correctional staff and detainees, which has a positive impact on the detainee's behavior. Detainees housed in 9-1 F are housed alone and come out of their cell alone. They are allowed 1.5-3 hours out of cell depending on their behavior and receive direct behavioral modeling from the DOC staff that remain on the unit with them during hours out of cell. The tier is managed by the DOC's Emergency Response Team, with shift reports distributed to the DOC Executive Staff detailing detainee behavior and overall compliance with the rules. Some of the most problematic detainees have successfully matriculated through the general population SMU and been allowed the
opportunity to participate in divisional programs.

When a seriously mentally ill detainee receives a disciplinary infraction, he/she is consequence with no more than 14 days in the SMU for each incident from the Inmate Hearing Board. When a

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detainee with serious mental illness has multiple disciplinary infractions, ongoing collaboration occurs between DOC and Cermak to develop behavioral management plans.
If a detainee is identified as P4, he/she is not placed in restricted housing until they are deemed stable for transfer to a lower level of care.
November 2016 Metzner assessment: Substantial compliance continues
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
t Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional to determine the inmate's mental heallth status, which shall include an assessment of the potential effect of segregation on the inmate's mental health. During these regular evaluations, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compl.ianc'e Assessment: Substantial compliance (11115)
Factual Fillldings:
November 2016 Cermak Status Update
CCDOC Administration brought in the State of IL statutory compliance their disciplinary SMU process and, presently, detainees' stay in disciplinary SMU cannot exceed 29 days, whereupon, they are removed from SMU and undergo additional review in order to determine whether they need to be put back in segregated setting. Mental Health Department continues to provide 24 hour SMU screening for this cohort of detainees reentering restrictive settings. Mental health

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staff continues to conduct rounds on restrictive housing units at minimum weekly (in addition to the rounds conducted by Nursing/PCS). New updated universal SMU placement notification sheet has been created and implemented. Detainees moving from one segregation tier to another are not in need of additional screening, however are documented on the notification sheet for institutional purposes. Mental health, unable to differentiate between those who were in need of a screen from those who are not, count the compliance rates at face value. Please refer back to Div. IX updtaes for discussion. Please see PDF Appendix for SMU Screening Compliance data.
To centralize the notification to Cermak mental health and nursing staff of detainees placed in Special Management Units, both agencies agreed upon a revised process that mimics the successful bed control notification process. Cermak leadership will be creating an SMU Notification email address that will be used by the DOC Classification unit to provide daily notifications.
November 2016 Metzner assessment: Substantial compliance continues
n. Cermak shall ensure that a psychiatrist, physician or licensed clilllical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
Complianc,e Assessment: Substantial compliance (4/16)
Factual Fillldings:
November 2016 Cermak Status Update
A restraint audit completed by the Cermak nurse manager, Madonna Mikaitis, R.N. can be found in the PDF Appendix.
Notifications to Facility Director/Chief ofPsychiatry are issued via a new process whereby nursing staff scans and emails those notification forms. Chief of Psychiatry continues to review the charts once either a restraint or therapeutic seclusion has been employed during one 24 hour period pursuant to the IL Mental Health and Developmental Disabilities Code. Cermak Policy I-01 Restraint and Seclusion was reviewed and updated in September 2016 to reflect that: When issuing restraining orders for special populations (i.e. pregoant females, morbidly obsess with BMI> 40, BMI.35 with comorbidity, complex individual behavioral management treatment plans), patients will be evaluated and treated on a case by case basis.

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November 2016 Metzner Assessment: QI orders demonstrated continued compliance.
Recommendations: Continue to monitor the QI process.
o. Cermak 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 adnllnistrative segregation or observation status.
p.. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
Compliance Assessment: partial compliance
Factual Findings:
April2016 Cermak Status Update
The collection of the HSRF response data reflects face to face evaluations conducted by mental health specialists by level of ordered priority (see Excel Appendix). Compliance with responding to all HSRF with a face-to-face evaluation within the required timeframes has continued to show improvements, specifically in response to Urgent and Priority health services requests. Currently approximately 95% of the Urgent HSRF are seen on the same day that the request is received and close to 90% of requests deemed a priority are seen within 48 hours of receipt of the request. While this trend is encouraging, response to routine requests continues to fall below expectations with approximately 70% of routine requests for services being seen within 72 hours of receipt of the request. One known factor continues to be delayed scheduling of appointments related to staff allocation and staff attendance. The second full-time mental health specialist that was previously assigned to Div. 9, one of the problematic areas, had to be reassigned to Div. 10 due to compound housing changes and reassignment of mental health patients. Unfortunately, despite the decrease in mental health patients in Div 9, mental health has not noticed a decrease in HSRF needing a mental health response. Female services has been short two licensed mental health specialists for an extended period of time, which has made adherence to HSRF timeframes more challenging. Other areas are impacted by staff absenteeism and sheer volume ofHSRF submitted. There are just far more patient requests for services than we have the staff to respond to in the required time frames. As such, clinics fill up quickly and appointments are scheduled further and further back. We incorporated these issues into our proposed staffing plan for the 2017 budget cycle, as expect that that we would see improvements in response time with increased staff numbers. As a department we continue to discuss ways in which to address the challenges associated with responding to repetitive and misused requests (i.e. detainees who fill out numyrous requests for secondary gain). We also expect that as the protocols and procedures for the processing ofHSRF becomes more fluid within Cermak as a whole; the mental health response time will improve. Patient Care Services staff continues to be provided education as to the appropriate handling ofHSRF for mental health services. Cermak leadership is also engaged

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 82 of 110 PageID #:5212
Appendix IV The Agreed Order Status Update Page 51 of 55
in discussion with the IT department about updates to the documentation of mental health HSRF in the medical record that would allow more efficient documentation of face to face triage by the QMHP and minimize "missed data" that is interpreted as a patient not being seen when that may not have been the case.
There is diminished concern regarding the number of HSRF that were classified as "not seen" by absence of documentation reflecting an evaluation in the medical record. The number in this category has not only significantly decreased in comparison to prior visits, but review of the records reflect that most of the HSRF had either been responded to by a QMHP, however the response was documented within the HSRF ad hoc document in the EMR which is not currently captured by the data . This is being addressed with IT. Remaining "not seen" were due to patient refusals and erroneous referrals to mental health that were not mental health related and did not warrant a mental health evaluation. The ChiefPsychologist will monitor "Not Seen" patients to ensure access to care is consistently and appropriately provided.
To expand the availability of crisis response to divisions, additional telehealth equipment was installed in the urgent care. With this additional equipment, when there are two mental health providers scheduled to the urgent care, divisional services needs have increased access. This has been of specific benefit with regard to screening the often high numbers of individuals that enter segregation on a daily basis.
April2016 Metzner assessment: QI data documents issues in meeting timelines for responses to routine mental health referrals related to the current policy and procedure that requires a face to face triage for routine referrals within 72 hours and periodic delays in receiving the referral from nursing staff in a timely manner. I discussed with staff potential revisions to the pertinent policy and procedure that will significantly decrease the lack of compliance. In addition, the process involved with the sending of the mental health referrals from the nursing staff to mental health services needs to be improved.
Recommendations: As above. Refer to the medical monitor's report.
November 2016 Cermak Status Update
There have been minimal changes in the response to or compliance with timeliness in responding to HSRF since the last site visit, as the data has remained relatively unchanged. The primary reason for delayed response to HSRF are largely attributable to staff allocations (more than 50%). However, this trend is actually encouraging given that we have experienced a decrease in staff allocation since the last visit. This means staff have placed increased focus on the completion of this task and maintaining access to care for our patients. This has unfortunately come at the detriment of other clinical activities, such as clinical groups and community meetings. Please see Excel and PDF Appendix.
November 2016 Metzner Assessment: As per status update section.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 83 of 110 PageID #:5213

Appendix IV The Agreed Order Status Update Page 52 of 55

Recommendations: Complete the previously referenced staffing needs assessment.

60. Psychotherapeutic Medication Administration

a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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.
Compliance Assessment: Partial compliance

Factual Findings:

November 2016 Cermak Status Update

Periodic monitoring of blood levels of Lithium and Depakote is important for the safe administration of the said medications. It is suggested that blood levels are checked at least every 6 months, even if a patient remains asymptomatic and the dosage remains unchanged. A new Cerner alert was created. The logic now exists in EMR and, when Providers (both Medical and Psychiatric) try to order and, more importantly, reorder Lithium and Divalproex, a new rule fires. If no Li and VPA levels have been ordered over the past 6 months, it prompt the system to order Li and VPA levels. As demonstrated by the chart, the frequency of medication monitoring has reached levels well above 90%.

Periodic monitoring of metabolic indices is essential for the safe administration of second generation antipsychotics. Chief of Psychiatry proposed that an alert be created to ensure timely monitoring of blood glucose levels and lipids against the backdrop of the administration of second generation antipsychotics. The whole CCHHS Health System adopted this new initiative in October 2016. The new alert is now operationaL The new rule will automatically fire with the tests for Non-fasting Lipids, Hb AlC, and weight measurement, if the said tests have not been performed over the past 6 months.

Critical Medications Missing Alert is being built in Cemer. It would capture weekly instances of patients missing critical medications (including Clozapine and Decanoate formulations). This report is going to trigger a review by nursing and further notifications of Providers.

#of Med 10 27 .~Wl6 Order(person)

#ofLab Order

Ratio

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 84 of 110 PageID #:5214
Appendix IV The Agreed Order Status Update Page 53 of 55

I Lithium

I

Divalproex

Sodium/

Valproi~ Acid I

Risperidone/

Ziprasddone/

Olanzapine

24

24 1 1oo.oo% I

1 8 2 1 0 1 96.15% I

564

251 I 44.50% I

November 2016 Metzner Assessment: As per current status update section

Recommendations: Repeat the audit after training the psychiatrists relevant to the new alert system.

E. SUICIDE PREVENTION MEASURES

62. Suicide Precautions

a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established
jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks. c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff. d•. Cermak shall develop and implement policies and procedures for suicide l precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.

CompHance Assessment: Substantial compliance (11/15)

Factual Findings:

April2016 Metzner assessment: Substantial compliance continues

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 85 of 110 PageID #:5215
AppendixN The Agreed Order Status Update Page 54 of 55
November 2016 Cermak Status Update
See PDF Appendix for Suicide Detection and Prevention QI Report Qtr. 1-3 2016
November 2016 Metzner assessment: Results of the above referenced QI report were consistent with continued compliance.
65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11/15)
Factual Findings:
November 2016 Cermak Status Update
Please refer to QI reports referenced in provision #62.
Novemb,~r 2016 Metzner assessment: Review of the relevant QI results were consistent with
the presence of continued substantial compliance.
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b.. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
Compliance Assessment: Substantial compliance (11/15)
Factual Findings:

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 86 of 110 PageID #:5216
Appendix IV The Agreed Order Status Update Page 55 of 55
November 2016 Cermak Status Update
Several additional QI projects have been undertaken since the last site visit, referenced throughout this report and/or found in the PDF Appendix.
Mental Health Disposition at Intake Psychiatric Diagnoses, Self-Injury, and Disciplinary Status of"High Disruption" Detainees Disciplinary Beds in Segregation & Self-Injury Cermak Dayroom Hours HSRF Reason for Delay/Not Seen
November 2016 assessment: The pre-site information packet, which included the QI appendix, was well done and extremely helpfuL The QI studies were methodologically sound, well written and very relevant. Substantial compliance continues.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 87 of 110 PageID #:5217 Re: Mental Health Services at CCDOC
USA v Cook County, et al. Page 8 of13
AppendixV

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 88 of 110 PageID #:5218
Appendix V Re: Document requests Page 1 of3
Please have the following information available in hard copy at the time of the site visit, and sent to me one week prior to the site visit in electronic form (but not in PDF) unless indicated otherwise. Each piece of information should cover the period since the last site visit.
Note: If any of the requests are too burdensome to produce, please contact me before attempting to produce such information.
Appendix [Agreed Order 5/13/10 MH provisions revised
Using the word version of Appendix IV in my last submitted report, after each of the "recommendations" section add the following section: [date of site visit] Cermak status update: and complete a narrative with proof of practice as available. This document request is the most crucial document. Please do not delete my November 2016findings or recommendations exceptfor provisions that have beenfound in substantial compliancefor at least ~8 months..
Some of the following requests may be in the above document and only need to be referenced-it does not have to be provided twice.
Mental llealth System
1. The mental health system organization chart (with both position and name ofperson filling the position and his/her credentials- e.g., degree).
2. Any new policies and procedures relevant to mental health services.
3. Any new program descriptions of the current mental health system.
4. Any other reports (i.e., internal or external reviews) relevant to the mental health system at CCDOC.
fustitutional Program Status
1. Narrative snmmary of program statns
Staffmg
1. List authorized mental health staff positions by discipline (psychiatrists, psychologists, social workers, nursing staff, clerical staff, etc.) and by program/area (intake, crisis stabilization, mental health housing units, etc.). For each position, indicate the person's name, professional degree, start date, and percent ofFTE if not full-time. Ifthe position is vacant, provide the date it became vacant. For any staffon leave, indicate the date the leave began.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 89 of 110 PageID #:5219
Appendix V Re: Document requests Page 2 of3
2. List any newly allocated mental health positions and the dates they were established.
Census/J1viental Health Roster
1. The total number of inmates in the jail, total number in segregation units, total number of mental health caseload inmates, and total number of inmates in each program area (crisis observation, mental health housing, general population, etc.).
2. Statistical information pertinent to the reception center screening of inmates (i.e., number of persons on a daily, weekly, or monthly basis for the past six months, percentage of inmates who have positive screens from a mental health perspective, percentage of inmates with positive screens who enter the continuum of mental health services, percentage of all newly admitted inmates who enter the continuum ofmental health services).
Access t(]) Higher Levels of Care
1. Number of inmates admitted to the infirmary on a monthly basis and the median length of stay in such beds.
Quality Improvement
1. Agenda and minutes of all CQI meetings. 2. Agenda and minutes of all Mental Health Subcommittee of the CQI meetings 3. A copy of each relevant QA/QI audit conducted, preferably in electronic forms. For each
audit provided, a description of:
a. Statement of the issue being studied b. Methodology used c. Results d. Assessment of results {: e. Plan of action based on the assessment
Medication management
1. List of inmates and/or logs or other documentation of inmates receiving medications on an involuntary basis.*
2. Audits or other documentation oftimeliness ofmedication delivery to inmates who arrived at the institution with current psychotropic medication orders or adequate verification of current psychotropic medication usage.
3. Audits or other documentation oftimeliness ofmedication delivery upon expiration of prior psychotropic order.
4. Audits or other documentation of practices identif'ying patients noncompliant with their psychotropic medication (as defined in policy), timeliness ofreferral to mental health, and timeliness and adequacy ofpsychiatric response.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 90 of 110 PageID #:5220
Appendix V Re: Document requests Page3 of3
5. Audits or other documentation of laboratory testing orders as per standards for psychotropic medications, timeliness of results, timely notice regarding abnormal results, and appropriate medication adjustments.
6. The total number of mental healthcare caseload inmates prescribed medication.
Suicide Prevention
1. For any completed suicide, a copy of the mortality and review report.
2. Agenda and minutes of Suicide Prevention team meetings
Additional Items
1. Schedule of group therapies/structured out of cell therapeutic activities offered to inmates in the mental health housing units.*
2. Logs showing the use of restraints and seclusion, including the dates and times the orders were initiated, renewed, and discontinued, and the timing of nursing checks conducted.*
3. Audits relevant to tbe mental health screening and rounds in the segregation units.
4. Description of the status of any new construction or remodeling for mental health treatment space.
*Does not need to be sent in advance ofsite visit.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 91 of 110 PageID #:5221 Re: Mental Health Services at CCDOC USA v Cook County, et a!. Page 9 of13
Attachment A

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 92 of 110 PageID #:5222 Attachment A

Dorm 1
Program
Alcoholics Anonymous Chess Narcotics Anonymous Sheriff's Anti-Violence Effort (S.A.V.E.)
Dorm2
Program
Alcoholics Anonymous Meditation Yoga
Dorm3
Program
Alcoholics Anonymous Art Houses ofHealiug
Dorm 4 (Workers' Tier)
Program
None

Number of Hours/Week I 4.5 I 45
Number of Hours/Week I 2 1.75
Number of Hours/Week I 2.5 1.5
Number of Hours/Week None

Number of Participants 15 12 13 Currently 25; Up to 48 -
CHouse
Number of Participants 15 20 40
Number of Participants 15 15 10
Number of Participants None

DIVISION 3 AX
Program
Alcoholics Anonymous Kennel Urban Farming Garden
DIVISION 4
Program
Alcoholics Anonymous Narcotics Anonymous Art Therapy (Murals) Book Club Knitting Meditation Piven Theatre Group Psychoeducation

Number of Hours/Week I 31.5 29.25

Nurnber of Participants
40 15 15

Inmate Serv1ces Programmmg- General Population/Floor 2

Number of

Number of Participants

Hours/Week

I

65

I

65

2.5

6

12

3

25

1.5

20

2

18

4 h/w for Tier 12; 3 h/w for tier P2; 1 h/w for tiers J2, Q2,L2

I2 4 hrs. X 15; P2 3 hrs. X 15: Q21hrX 15;J21 h< X 15 and L21 hrX 15

Still Point Theater Collective Storybook Project
Program
Adoption Center ofiL at Family Resource Access Conununity Health Network Art Thera -Sister An ele

1.5 3 hrs/wk, once a month
DWJS Programmmg-Floor 1
Number of Hours/Week 1.5 4 4

20 12monthly
Number of Participants
20 35 3

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 93 of 110 PageID #:5223

I Yoga for Recovery I CPS

12
Education

DIVISION6
Program
Alcoholics Anonymous Larry's Barber College Houses ofHealing Male Leadership Meditation (Claire Seryak) Meditation (Scott Chambers) Narcotics Anonymous
Storybook Spanish-Speaking Alcoholics Anonymous Transgender Group Yoga
DIVISION 8 RTU
Program
Art Therapy Book Club Houses ofHealing Organic Mentoring Successful Women Think Differently Yoga
DIVISION9
Program
Alcoholics Auonvmous Literacy Empowerment Man Up Men's Wellness Group Narcotics Anonymous Storybook -Law Library Transgender Group Yoga/Mindfulness/Meditation
DIVISION 10
Program
Alcoholics Anonymous Ethics Class Meditation Storybook
DIVISION 11
Program
Alcoholics Anonymous Anger Management Chess Drums Guitar Lessons Cermak Administered Health Education

Number of Hours/Week I 18 I I 3 2 I
3 hrs, once a month 1.25 2 I

Number of Participants
45 15 45 40 40-TIER2H 20 120- TIERS 2A,B,&C, 2Q, 2R 12 monthly 10 30 20

Number of Honrs/Week 2 I 1.5 I I 2

Number of Participants
12- Tiers 5C & 5D 15 10- Tier 5E 30 20 -Tiers 5G & 5H 15 - 5th floor

Number of Hours/Week I 1.75 I 50 I 2.5 hrs, once a month 1.25 I

Number of Participants
45 45- Tier 1D 45- Tier 1D 90- Tiers IC & 1D 90- Tiers IC & 1D 12, monthlv 5 45- Tier IC

Number of Hours/Week I 1.5 I
2.5, once every TWO mo.

Number of Participants
40 15 20 Varies based on request

Number of Hours/Week I 2 4 4 1.5 9

Nnmber of Participants
40 20 16 10 15 15

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 94 of 110 PageID #:5224

CCDOC Enrichment Programs

Division 2

Division 11

• 13 hours weekly of enrichment programs

o involving a total average of 117

• 46.5 hours of weekly enrichment programs

participants

o involving a total average of 306

o who attended 11 group sessions

participants

• 44% 12-Step

o who attended 22 sessions.

• 33% Personal Transformation

• 50% Personal Transformation

• 22% Creative Expression

• 29% Creative Expression

Division 3-Annex
• 51 hours of weekly enrichment programs o involving a total average of70

• 14%12 Step • 7% Vocational

participants

o who attended 11 group sessions
• 95% Vocational

• 5% 12-Step

Division 4

• 74 hours of weekly enrichment programs

o involving a total average of 810

participants

o who attended 54 sessions.

• 52% Personal Transformation

• 26% Creative Expression

• 19%12 Step

• 4% Vocational

Division 6
• 33 hours of weekly enrichment programs per

week

o involving a total average of 443

participants

o who attended 16 sessions.

• 55% Personal Transformation

• 27%12 Step

• 9% Creative Expression

• 9% Vocational

Division 8-RTlU
• 11.5 hours of weekly enrichment programs o involving a total average of 102 participants o who attended 9 sessions. • 67% Personal Transformation • 33% Creative Expression
Division 9
• 29 hours of weekly enrichment programs o involving a total average of 368 participants o who attended 13 sessions. • 56% Personal Transformation

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 95 of 110 PageID #:5225
CCDOC Totals as of 10/11/2016
• 2'62.5 total average number of hours of weekly enrichment programming • 2291 average participants • 140 sessions
Notes:
• Group sizes vary- current emphasis being placed on conducting on-living unit programming as frequently as is feasible. Divs 4, 6 and RTU are most impacted by this.
• Data reflected above may include participants who are active in multiple programs. • Personal Transformation programming encompasses Psycho-Education, Health Education,
Vocational, Yoga, Meditation, Mindfulness, Emotional Intelligence, Literacy, Anger Management, Conflict Resolution, and Impulse Control. Some of the key curricula currently being emphasized by CCDOC Enrichment Program staff and Interns includes:
o House of Healing- used in Jails and Prisons throughout the Country and focused on Emotional Literacy
o Discovering Ethics: A Path to Virtue based upon HH the Dalai Lama's book "Ethics for the New Millennium"- Study Guide adapted by The Prison Mindfulness Institute- a values based curriculum
o Thinking for a Change an integrated cognitive behavioral change program used in Prisons and Jails throughout the Country. Used in MHTC.
o Path of Freedom a mindfulness-based emotional intelligence curriculum designed by The Prison Mindfulness Institute
• Creative Expression programming encompasses Music, Art, and Theatre.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 96 of 110 PageID #:5226 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 10 of13
Attachment B

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 97 of 110 PageID #:5227

Cermak Health Services

Functional FTE's

11/1/2016

11/1/2016 FTE Psychiatrists and Psychiatric PA

Chair (1)

1.0 (Kelner)

Attending Psychiatrists McNeal, Haq, Miller)

9.8 (Advani, Howard, Marri 0.8, Menezes, Paschos, Ward, 8ednarz,

Psychiatric PA {2.)

1.1 (Balawender, Locums -Bastidas 0.1)

Psychiatrists Overtime

0.2 (Howard, Moreno)

Psychiatrists (133 acct)

1.5 (lassen, Chinweze, Ramie, Chavlayohan, Kartan)

Consulting Psychiatrist

0.3 (Binius)

Psychiatrist Locums

1.0 (Garb, Pandit}

Total Functional FTE

11/l/2.016 rn Psychologists

Chief Psychologist (1)

1.0

Psychologists (10)

6.0

(K. Key) (Briney, Kaniuk, Waxler, Sillitti, Nunez, Augustine)-

Total Functional FTE

11/1/2016 FTE Mental Health

Mental Health Director

1.0 FTE Gomez

Admin. Asst.

1.0 FTE Burnett

Medical Social Workers

7.0 FTE Musa, Hinds, Tomlin, Mojica, Hooks, Posten, Escamilla

MH Specialists

60.0 FTE (53 licensed***, 7 unlicensed****)

Art Therapists

3.0 FTE

Total Functional FTE

72.0

Department of Mental Health 93.9

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 98 of 110 PageID #:5228

• Consulting Psychiatrist ( PT Psychiatry)- Cherian is in credentialing

• Kartan (FT Psychiatry)-present!y part time; was given a job offer FT; pending acceptance

• Jonsson ( FT Psychiatry); anticipated start January 2016- she is already credentialed as she was employed by JSH until April 2016

• Greiner (FT Physician Assistant); presently in credentialing

• Bastidas (Locums Physician Assistant); being let go in December for performance related issues

• Martinez (Psychology FT) is done with credentiafing; had anticipated start November 2016;

withdrew from consideration

• Quant { Psychology FT) submitted DTH

• MHS: out of 60 filled PID's:

-1 ( Radici) (credentials/security clearance pulled 10/15/2015, extended administrative

paid leave since November 2015)

-1 (Thomas) (modified leave of absence)

• Summary of Vacancy Rates:

Psychiatry Full Time

Filled
10

Vacant/Vacancy Rate
5 (33.3%)

Total 15

Psychiatry Part Time Filled 6

Vacant/Vacancy Rate 2(25%)

Total 8 (SPT and 3 Consulting}

Psychology Full Time
Riled 6

Vacant/Vacancy Rate 4(40%)

Total
10

Physician Assistant
I Filled
. 1

I Vacant/Vacancy Rate l(SO%)

Mental Health Specialists Filled
60

Vacant/Vacancy Rate 10(14.2%)

Total Vacancy Rate 18%

Total 2
Total 70

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 99 of 110 PageID #:5229 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 11 of13
Attachment C

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 100 of 110 PageID #:5230

Attachment C

POSITION TITLE
Divisional Chief of Psychiatry FT Psychiatrist PT Psychiatrist PT Psychiatrist Consultant Chief Psychologist Psychologist Physician Assistant Socillll 'Yorker Mental Health Director Art Therapist MHS Administrative Assistant Locums Psychiatrist LocumsPA
TOTAL

ACCOUNT #

VACANT

FILLED

SUM

% VACANT

110

0

1

1

0.0%

110

5

10

15

33.3%

133

0

5

5

0.0%

155

2

1

3

66.7%

110

0

1

1

0.0%

110

4

6

10 40.0%

110

1

1

2

50.0%

110

0

7

7

0.0%

110

0

1

1

0.0%

110

0

3

3

0.0%

110

10

60

70

14.3o/o

110

0

1

1

0.0%

2

2

0.0%

1

1

0.0%

22

100 122 18.0%

%VACANT BY TITLE

70.0%

66.7%

60.0% 50.0% ~

. . ~·---· ~~----

40.0%

---33~3%--

---~-~ 30.0%
20.0% .

---- ---

10.0%

0.0%

POSITION

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 101 of 110 PageID #:5231
The main task remains attracting full time Correctional Psychiatrists through assertive national search and advertisement campaigns.
There are 5 part-time Psychiatrists and in that group all the vacancies have been filled. The majority of part-time (Account 133) Psychiatrists are committed to working between 8 and 20 direct service hours. There is one filled position of a Consulting Psychiatrist. The rate of compensation for this position has been made sufficiently attractive.
The rate of compensation for Physician Assistants remains below what is average in the Chicago market.
Recruitment in process: +2 Psychiatrist candidates selected and in process (Kartan and Jonsson) +.25 1 Consulting Psychiatrist candidate selected and in process (Cherian) + I Physician Assistant candidate selected and in process (Greiner)
In June 2015 Cermak Mental Health submitted paperwork necessary for the creation ofthe new non-union position ofthe Associate Chairman/Divisional Chair for Psychiatric Special Care to assist the Chief ofPsychiatry in clinical and administrative duties. As of October 2016 the creation of this position has not been cleared.
Cermak has contracts with 3 (three) staffing agencies to provide Locum Tenens Psychiatrists: MedicalDoctor Associates (.MDA), Maxim Physicians Resomces and Columbus Organization. The fomth (Re-Group Inc.) is being added. All Vendors' contracts have Amendments for Telepsychiatry. Dr. Garb, furnished by Columbus, is deployed on site at Cermak in Division X. Dr. Pundit (Maxim) started providing direct service homs in Division X as a Telepsychiatrist in September 20916. The contracts for the three locum tenens agencies have been extended into 2017. Based on present clinical needs and recruitment yield, Cermak Mental Health Department projects that we will continue to need staffing assistance. Some of the Locums Psychiatrists who are currently in the credentialing process did not complete it. One Locums Provider decided not to pmsue this position after the first two weeks of Orientation.
Ongoing current advertisement efforts by CCHHS involved postings in industry publications, including the AAPL quarterly letter, communication with the local feeder schools, and participation in local Psychiatry Fairs (October 2016).
On the CCHHS Job Site there has seen a significant increase in visiting candidates for this reporting period (June- Sept 2016) compared to the previous reporting period (Mar- May 2016). The specific metrics were for the Physician, Psychologist, Mental Health & Services and PA postings. There has been a credible increase in all candidate categories and, specifically, in the categories critical for Cermak. There was an averaged 44% increase in candidate views for this reporting period (June- Sept 2016) compared to the previous reporting period (Mar- May 2016) across all job categories.
,,

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 102 of 110 PageID #:5232
For psychiatrists, Salary increases for Kl 0, from $216,661 to $231,084, in addition to the same $15,000 Cermak differential, were made in April2016.
Additional staff hired in the CCHHS's Credentialing office will provide for increased support to engage applicants and expedite processing.
New "Advanced Clinical Process (ACP)" started as a pilot at Cermak in November 2015. The Advanced Clinical Process was created to assist Cermak in filling hard to fill credentialed positions. The ACP process has helped enhance the recruitment process by allowing for the participation of departments to solicit candidates to submit resumes I CVOs to a centralized mailbox, which allows for the expedited review and determination of candidates meeting
minimum requirements. Due to success of this pilot, the ACP process is now implemented
CCHHSwide.
In May 2016 Chief of Psychiatry submitted a program addendum to cooperative educational master agreement for rotation of Forensic Fellows from Forensic Fellowship Program at Northwestern University at Cermak. The identified need is to provide evaluations, prepare Petitions, and testify during trials for the Administration of Involuntary Medications (nonemergency basis).
Cermak Mental Health continues to support student and Psychiatry residents' rotations/training on site from nearby medical schools (Rush+ UIC's Master Educational Agreement is being renewed presently).
Vacancy Rates, PTE's and Net changes in vacant positions for Psychiatry is available in the PDF Appendix.
There is a total of 10.0 PTE psychologist positions (excluding the ChiefPsychologist position) with a current vacancy rate of 40% (4 FTE). One Correctional Psychologist resigned. Cermak has lost s1everal candidates in later stages of their hiring process due to the fact that their internships were not APA approved. Efforts are made to vet candidates early on to identify candidates whose internships would disqualify them from receiving clinical privileges at Cermak.
Recruitment in Process until end of October, when both candidates withdrew: +0 2 Psychologist candidates withdrew (Martinez had pending start date/Quant in credentialing)
For FY 2017, Cermak has submitted a request to fund 2 post-doctoral Psychology Fellows to work under the supervision of the Chief of Psychology, to provide diagnostic assessment, crisis intervention, intake evaluations, group and individual therapy, consultation with multidisciplinary treatment team, projective and objective psychological testing, security and civilian stafftraining, and supervision ofpracticum students.
There is a total of 70 MHS Specialist Positions with a current vacancy rate of 14.2 %. There are those who are presently enrolled in a Master's program and expected to be eventually licensed.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 103 of 110 PageID #:5233
They will be expected to complete their degree/licensure by specific, individualized dates (based on current status and anticipated licensure date).The ones who have matriculated Master's Programs and obtained licensure are being promoted into MHS III Positions. If these employees do not achieve licensure by their specified dates, their position will be eliminated. The first rounds of separations took place in July 2016. Presently, licensed staff (as they meet their educational and licensure requirements) is being promoted to fill positions vacated by the uulicensed staff. Some of the resignations, attrition, and internal transfers coincided with the first round of separations and caused a temporary increase in vacancy rates during the months ofJulyOctober of 2016. A staffing proposal calling for additional MHS III (licensed positions) was developed and submitted to Cermak Leadership for sponsorship. Cermak had submitted a FY 2017 Budgetary Request for a large number ofpositions for Cermak.
Cermak has received support for a number of positions, some of which were for the Mental Health Department. Approval by the Cook County Board of Commissioners is necessary and should be considered pending approval until that time. The start of the fiscal year is December I st. Cermak received support for 14 new Mental Health Specialist III positions and 1 Activity Therapist.
There is a total of 7 Medical Social Workers Positions. All the positions have been filled.
Positions of the Chief of Psychiatry, Chief Psychologist and Mental Health Director are filled.
Staffing Plan for FE 2017 has been developed by Cermak Mental Health Leadership and can be found in the Excel Appendix.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 104 of 110 PageID #:5234 Re: Mental Health Services at CCDOC
USA v Cook County, et al.
Page 12 of13
Attachment D

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 105 of 110 PageID #:5235

Attachment D

INVOLUNTARY HOSPITALIZATION BY PETITION & CERTIFICATE UPON

RELEASE 2014-16
YEAR~ FEB MAR
2016 3 3 4 2015 3 7 2 2014 3 5 4

D t t j APR MAY JUN II JUL AUG SEP OCT NOV DEC TOTAL

4 2

1 4 IT:::JI I 39

2 4

13 14

IIsB_g[oL

13 ]4

12 13

4 4

6 3

3 4

45 48

INVOLUNTARY HOSPITALIZATION Q1-Q4 2014-16

I I I YEAR Ql 02 Q3 o4 TOTAL

lis 2016 10 13 11

1139

Is 201S 12 lS

1113 132

2014 12 13 11 111 1148

Detainees meeting criteria for the administration of involuntary medications (non -emergency basis) continue to be evaluated for filing of the Petition. Some patients refuse to accept psychotropic medications, sometimes even in cases when their safety and survival depends on their receiving treatment. In those cases, judges are petitioned to authorize involuntary treatment. Typically our petitions for the administration ofinvoluntary treatments are heard by the judges at the Circuit Court of Cook County. Cermak's petitions for the involuntary administration of psychotropic medications undergo vigorous judicial review and are not afforded the administrative review process. While preparing these petitions requires many hours ofmedical research and clinical data analysis, this painstaking process is made even more difficult by the fact that Psychiatric Providers have to travel to the Daley Center for the hearings.
It was suggested that petitions for the involuntary administration ofpsychotropic medications be heard by Judges at the Leighton Center (26th and California), thus reducing Cermak's travel and time expenditures. Furthermore, Dr. Kelner contacted ASA Office seeking additional information and guidance in finding out ifthe Harper Procedure afforded to detainees in IDOC ( Administrative review ) can be applied to CCDOC detainees in lieu of the Judicial Review that we currently use to petition for the administration ofinvoluntary medications (non-emergency basis).
Cermak Mental Health has put forth a new initiative in order to facilitate and streamline petitions for the administrations of involuntary medications for pretrial detainees at Cook County Jail. A two-member review committee. This committee includes representatives ofthe Mental Health Department Administration: Director ofthe Mental Health Department (Chief ofPsychiatry) and Chief Psychologist. The Committee performs the following functions:
1. The Committee assist psychiatric Providers in the process of selection ofpatients meeting criteria for the involuntary administration ofpsychotropic medications. The committee's finding and recommendations have advisory power and the Committee will work closely with Providers in order to efficiently identity and select Patients who are in need oftreatments.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 106 of 110 PageID #:5236
2. The Committee works with Providers assisting in filing the motions for the "modification" of petitions granted in Cook County so that they be applicable at the DMH facilities located in different counties of the state of Illinois. Conversely, assistance will be provided in having orders "domesticated "to Cook County for detainees returning from DMH facilities in outlying counties.
Judge S. Sullivan and Assistant General Counsel, Cook County Health & Hospitals System J. Dimoff guided Cermak in the exploring various alternative arrangements to replace/supplement MH Court hearings at the Dailey Center. As the result of their efforts, some of the Petition hearings have been conducted at the Leighton Center and, more importantly, an attempt was made to start conducting those hearings from Cermak Basement using the already existing Polycom teleconferencing equipment.
New Rule governing the use ofvideoconferencing equipment in hearings under the MH and Developmental Disabilities Code was approved by the Circuit Court of Cook County in September 2016. It was designed to facilitate fair, just, and clinically appropriate hearings for persons in need of psychotropic medications by court order and reduce clinically inappropriate and burdensome transportation of persons with SMI from mental health facilities and jail to courtrooms. Cermak was able to identifY a physical location/lighting and security arrangements for the respondent and his counsel and other participants. Videoconferencing equipment at Cermak was compatible with the court's system. However, the results of the pilot teleconferencing hearings were not satisfactory in that the existing conferencing capabilities do not measure up to the standards necessary to assure the integrity of court hearings should the respondent and his counsel as well as ASA are present at Cermak altogether. An ad hoc possibility remains that Providers (witnesses) are allowed to testifY in these proceedings from Cermak yvhile the Judge, respondent, counsels, and witnesses are located in a courtroom elsewhere. The room and equipment previously identified will only work when there is one witness (Provider) testifYing from the hospital. This can only happen when the respondent has elected not to be present, the attorneys agree and the court so orders. There is a CODEC Video-conferencing machine in Markham Courthouse that may be of assistance at Cermak. Office of general Counsel, CCHHS is actively assisting in exploring the possibility of transporting this equipment to Cermak to facilitate videoconferencing hearings. The said equipment is able to pan, tilt, or zoom, which is necessary to adequately conduct the hearings in compliance with the newly adopted Circuit Court Rules governing such proceedings.
Between exploring new venues for Petition hearings, receiving active support from the Office of General Counsel, CCHHS and Judge Sullivan, and capitalizing on new staffing allocations, Cermak has filed 15 petitions for Involuntary Medications in 2016 thus far. As a reference point, in 2012 there were 4 petitions filed altogether. This surge in Petitions represents almost 300% mcrease.

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 107 of 110 PageID #:5237

INVOLUNTARY MEDICATIONS BY YEAR

16

14

12

f- 10

z

::J 8

I I I u0 6

4

2

I

0

2012

2013

2014

2015

2016

2017

YEAR

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 108 of 110 PageID #:5238 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 13 of13
Attachment E

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 109 of 110 PageID #:5239
NURSING DEPARTMENT -CENSUS REPORT FY2016

CENSUS

AVG

- --+-----

TOTAL PAT,
....TI~~~~~ll.._~II§C::.H~Ifl:(;<f:l) ~- DAYS

AVG LENGTH OF STAY

TRANSFERS

TOTAL PAT,
.. -··y--·· ......... +-·····-···-·····-- c· .········- ·I
Page 1 of 5

Case: 1:10-cv-02946 Document #: 339 Filed: 12/12/16 Page 110 of 110 PageID #:5240
NURSING DEPARTMENT -CENSUS REPORT
FY 2016

CENSUS

AVG

RECEIVED BY ADMISSIONS TRANSFER

TOTAL PAT, DAYS

AVG LENGTH OF STAY

MONTH

CENSUS

AVG

_____,___ _
5 8

-------
' ------ -..----- '-· ----- 5
6 ---

! - -----;;~;- ·····- -e----~c_;:.;-;;---1

,_ -+---r----.-----
. ----·- -]----
Page2 of 5

 
 Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 1 of 56 PageID #:5257 NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

UNITED STATES OF AMERICA,
Plaintiff,
V.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK'COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants,

No. 10 C 2946 Judge Virginia Kendall

Monitor Harry E. Grenawitzke’s Report No. 13 Fire, Life Safety, and Environmental Health December 16, 2016

Harry E. Grenawitzke, RS, MPH, DAAS Grenawitzke & Associates, LLC 50 Sheridan Drive Monroe, MI 48162
E-mail: harry.grenawitzke@gmail.com
Page 1 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 2 of 56 PageID #:5258
Executive Summary
December 5-8, 2016
This report summarizes the findings from the 13th tour of CCDOC. This tour completes the last of three tours established by the Consent Agreement between Cook County and the US Department of Justice Civil Rights Division that measure whether Cook County Department of Corrections (CCDOC), Department of Facilities Management (DFM) and Cermak Health Services (CHS) are able to sustain all provisions for fire, life safety and environmental health. At the tenth tour all CCDOC and CHS provisions assigned to the fire and life safety monitor were all judged to be substantially compliance. The eight provisions whose responsibility belonged to DFM were concluded in June, 2015 by Judge Virginia Kendall.
As a result of this tour, I conclude that all provisions of the Consent Agreement continue to be substantially compliant and that CCDOC and Cermak have sufficiently demonstrated sustainability of the requirements. It is important to note that CCDOC, DFM, and CHS should and will always have a need for continual improvement of these provisions as well as the operations, programs and services there. In most, if not all provisions, CCDOC, CHS and DFM have exceeded minimum requirements for compliance by continuing to review and improve policies, reviewing and improving effective training for their staff and the others as they apply across departmental responsibilities and implementing appropriate changes. All three continue to monitor practice against policies and procedures to identify non-conformities and ways to improve both effectiveness and efficiency.
CCDOC continues to grow its internal auditing team for policies and procedures and are reviewing audit reports measuring conformance and review and initiate documented corrective actions taken when necessary. This initiative will drive
Page 2 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 3 of 56 PageID #:5259
continual improvement in operations and sustain the initiative and changes made to date.
I recognize and congratulate the hard work of the Cermak Health Services staff and the Cook County Department of Corrections officers, supervisors, command staff and executive leadership for their roles to gain and exceed compliance and making the entire initiative successful for the detainees.
I would be remiss in my responsibilities to not specifically recognize the vision, commitment, dedication and the many hours of time of Executive Director Nneka Jones Tapia, former Executive Directors Cara Smith, John Murphy, Gary Hickerson, and Salvador Godinez, Department of Corrections Chief of Staff, Matthew Burke , Assistant Executive Director Deborah Boecker, and their staff at Cook County Department of Corrections; Bilqis Jacob-El, Director of Facilities Management and former Director James D’Amico and the staff from DFM; Connie Mennella, Chair Department of Correctional Health Services, Linda Follenweider, Interim Chief Operating Officer Cermak Health Services, Chris Wurth, Former Chief Operating Officer Cermak Health Services, and Scott Achterhof, Environmental Services Director from Cermak Health Services for the achievements they earned. This was by no means a simple assignment, but a consistent and cooperative effort of many people to recognize the needs of the detainees and staff within the organizations, change the culture, develop policies and procedures, make the necessary changes to improve operations, and develop a means to continuously measure improvements.
I express my appreciation to Sheriff Thomas Dart for his dedication, leadership skills, drive for excellence and continuous commitment for success to improve conditions of confinement within CCDOC and his expectation to continually assess programs, services and operations and make improvements where and when needed.
I express my gratitude to the US Department of Justice and in particular Ms. Kerry Krentler Dean for her wise counsel, outstanding leadership skills, and her continual willingness to assist not only me, but more importantly Cook County
Page 3 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 4 of 56 PageID #:5260
Department of Corrections, Cermak Health Services and Department of Facilities Management. She always has the right question at the right time for all of us to ponder. She too is a major contributor to the success of the initiative.
Since the tour in June, 2016, CCDOC continues to make significant strides in growing and in the number of internal audits completed that measure staff accountability for all CCDOC policies and procedures and a valuable tool to demonstrate “continuous improvement” in the management of Corrections. CCDOC leadership wants to know what is going well, what can be done to identify improvement opportunities and make effective changes to operations and services
Since that previous site visit, the most significant progress occurred in the following areas:
1. Improved analysis of pest control records and trending reports to reduce insect and rodent issues throughout the complex;
2. Improvements in new and replacement equipment for the food service operation including replacement of two well-used warewashers, replacement of all refrigeration compressors and condensers, new hot food transport carts, and significant repairs to the floor surfaces;
3. Significant improvements in the cleanliness and maintenance of housing areas, showers, exam rooms, and storage areas throughout the Cermak Health Care Facility and a development and implementation of a new electronic information system to continually monitor timely completion of housekeeping tasks;
4. A new and significantly improved cloud-based DFM work order system (FAMIS) that will provide useful and timely reports for both DFM and CCDOC to further improve response time;
5. CCDOC completed two internal audits training courses for over 60 staff and have another one planned. They have trained five lead auditors and
Page 4 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 5 of 56 PageID #:5261
are beginning the process to add ten to fifteen new auditors as they ramp up their internal audits of policies and procedures;
6. Revised fire safety policy, conducting much improved fire and smoke investigations, having less fires throughout all divisions, completing significantly more thorough fire and evacuation drill assessments, and significantly reducing combustibles allowed in housing units;
7. Completion of revised sanitation plans for all divisions, including robust schedules, specified cleaning frequencies housing units, common areas, hallways, offices and storage areas etc.;
8. Improved laundry usage by inmates for personal clothing. Implanting a robust tracking system and completing trend analysis for monitoring laundry use;
9. Implementation of a toll free inmate hotline to report living condition issues, thereby reducing lag time for submission of work orders, reduce number of grievances related to housing conditions, and allowing inmates the opportunity to initiate needed improvements. The new system is currently implemented in Divisions 2 dorm 4, Divisions, 4, 6 10 and 11. Future expansion will be in remaining Divisions 8, 9, 14, and Division 2 Dorms 1, 2, and 3; and
10. Continued reduction in detainees housed at CCDOC thus allowing the demolition of old, outdated, and costly to maintain buildings. That said there continues to be a need to identify replacement facilities as remaining buildings there are becoming very costly to maintain.
For this tour I again assessed implementation of policies and procedures established to address the fire and life safety and environmental health provisions for CCDOC and CHS Medical and Mental Health Facilities. As part of the tours I interviewed inmates, correction staff, supervisors, and management; held meetings with the fire safety committee, Department of Facilities Management staff, and Cermak management staff. I toured Divisions 3-Annex, 4, 6, 9, 10 and
Page 5 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 6 of 56 PageID #:5262
Cermak; laundries in Division 4 and 5, chemical distribution room in Division 5 and the Central Kitchen. Time did not permit me to visit every housing unit in the Division’s toured. However, the observations of the tiers visited provide the basis for this report. Throughout the tour I identified and discussed with staff and management issues where improvements can be made for the fire, life safety, and environmental health provisions. However no systemic issues were identified. As a result, all provisions continue to remain substantially compliant with the Consent Agreement. I will continue to be available to assist the Department of Justice and CCDOC, DFM and CHS management and staff to discuss and help resolve issues as they arise. It has been a pleasure to work with all three organizations and monitor the progress throughout the six plus years.
Sincerely, Harry E. Grenawitzke, RS, MPH, DAAS Monitor for Fire, Life Safety and Environmental Health
Page 6 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 7 of 56 PageID #:5263

Section

Summary June 29, 2016 Language

Substantial Compliance
Partial Compliance
Noncompliance

C.

Medical Care

C. 53 Treatment and Management of Communicable Disease

C. 53e Cermak shall ensure that the negative pressure and ventilation

3/11 9/10

systems function properly. Following CDC guidelines, Cermak shall 8/11 7/12

test daily for rooms in-use and monthly for rooms not currently in- 12/11

use. Cermak shall document results of such testing.

2/13

9/13

3/14

10/14

4/15

3/16

6/16

12/16

C. 53f Cermak shall notify DFM, in a timely manner, of routine and

7/12 3/11

9/10

emergency maintenance needs, including plumbing, lighting and 2/13 8/11

ventilation problems.

9/13 12/11

3/14

10/14

4/15

3/16

6/16

12/16

F.

Fire and Life Safety

F. 71 CCDOC and DFM shall work together to develop and implement a 12/11 9/10

fire safety program and ensure compliance is appropriately

7/12 3/11

documented. The initial Fire Safety Plan shall be approved by the 2/13 8/11

fire prevention authority having jurisdiction. The Fire Safety Plan 9/13

shall be reviewed thereafter by the appropriate fire prevention

authority at least every two years, or within six months of any

3/14

revisions to the plan, whichever is sooner. Fire safety and

10/14

emergency procedures shall be standardized across divisions, to the 4/15

Page 7 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 8 of 56 PageID #:5264

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

extent possible given differences in physical plant and security

3/16

levels.

6/16

12/16

F. 72 CCDOC shall develop and implement an evacuation plan for inmates 12/11 Not

and staff and ensure that comprehensive fire drills are conducted 7/12 Assessed

every three months on each shift. CCDOC shall document these

2/13 9/10

drills, including start and stop times and the number and location of 9/13 3/11

inmates who were moved as part of the drills.

3/14 8/11

10/14

4/15

3/16

6/16

12/16

F. 73 DFM shall ensure that the Facility has adequate fire and life safety

equipment, including installation and maintenance of fire alarms

and smoke detectors in all housing areas according to applicable

fire codes. Maintenance and storage areas shall be equipped with

sprinklers or fire resistant enclosures in accordance with City of

Chicago Fire Code (13-76-010).

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

F. 74 DFM shall ensure that all fire and life safety equipment is properly maintained and routinely inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the Life Safety Equipment.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

F. 75 CCDOC shall continue to ensure that emergency keys are

2/13 9/10

appropriately marked and identifiable by touch and consistently

9/13 3/11

stored in a quickly accessible location, and that staff are adequately 3/14 8/11

trained in use of the emergency keys.

10/14 12/11

4/15 7/12

3/16

6/16

Page 8 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 9 of 56 PageID #:5265

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

12/16

F. 76 CCDOC shall ensure that staff are able to manually unlock all doors 2/13 9/10

(without use of the manual override in the event of an emergency 9/13 3/11

in which the manual override is broken), including in the event of a 3/14 8/11

power outage or smoke buildup where visual examination of keys is 10/14 12/11

generally impossible. CCDOC shall conduct and document random 4/15 7/12

audits to test staff proficiency in performing this task on all shifts, a 3/16

minimum of three times per year. CCDOC shall conduct regular

6/16

security inspections of all locking mechanisms. CCDOC shall

12/16

communicate with DFM via the Work Order System regarding lock-

related issues and maintenance.

F. 77 DFM shall develop and implement an annual preventative maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

F. 78 CCDOC shall implement competency-based testing for staff

8/11 Not

regarding fire and emergency procedures.

12/11 7/12 2/13

assessed
9/10 X3/11

9/13

3/14

10/14

4/15

3/16

6/16

12/16

F. 79 CCDOC shall promptly notify DFM of all electrical hazards, including 7/12 9/10

maintenance and repair of electrical outlets, devices, and exposed 2/13 3/11

electrical wires.

9/13 8/11

3/14 12/11

10/14

Page 9 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 10 of 56 PageID #:5266

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

F. 80
F. 81
F. 82
G G. 83 G. 83a

DFM shall promptly repair all known electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires and will document repairs by the Work Order System.

4/15 3/16 6/16 12/16

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

CCDOC shall ensure that combustibles are controlled and eliminate 9/13 3/11 9/10

hi8ghly flammable materials throughout the facility and inmate

3/14 8/11

living areas (e.g., inmates ‘use of paper bags as trash receptacles, 10/14 12/11

ripped fire-retardant mattress covers, improvised cell light covers, 4/15 7/12

blankets on cell floors, and improperly stored and labeled

3/16 2/13

flammable liquids and other chemicals).

6/16

12/16

CCDOC shall ensure that fire safety officers are trained in fire safety 7/12 Not

and have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, and use of fire extinguishers and other emergency equipment.

2/13 9/13 3/14 10/14

Assessed
9/10 3/11 8/11

4/15

3/16

6/16

12/16

SANITATION AND ENVIRONMENTAL CONDITIONS

Sanitation and Maintenance of Facilities

DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate maintenance of the Facility.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

Page 10 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 11 of 56 PageID #:5267

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83b G.83c

CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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.
DFM 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.

4/15 3/16 6/16 12/16

9/10 3/11 8/11 12/11 7/12 2/13 9/13 3/14 10/14

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

G. 83d CCDOC shall notify DFM, in a timely manner, of routine and

7/12 8/11

9/10

emergency maintenance needs, including plumbing, lighting, and 2/13 12/11 3/11

ventilation problems.

9/13

3/14

10/14

4/15

3/16

6/16

12/16

G.83e DFM shall ensure adequate ventilation throughout the Facility to

ensure that inmates receive an adequate supply of air flow and

reasonable levels of heating and cooling. DFM staff shall review

and assess compliance with this requirement on a daily basis for

automated systems and on and annual basis for non-automated

systems.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

G. 83f

CCDOC shall notify DFM of any visible obstructions to the ventilation system.

7/12 3/11

9/10

2/13 8/11

Page 11 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 12 of 56 PageID #:5268

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83g G. 83h G. 83i G. 83j

Cook County shall ensure adequate lighting in all inmate housing and work areas.
CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed. CCDOC shall ensure that all inmates have access to needed hygiene supplies.
CCDOC shall develop and implement policies and procedures for

9/13 3/14 10/14 4/15 3/16 6/16 12/16 2/13 9/13 3/14 10/14 4/15 3/16 6/16 12/16 2/13 9/13 3/14 10/14 4/15 3/16 6/16 12/16 4/15 3/16 6/16 12/16
2/13

12/11
9/10 3/11 8/11 12/11 7/12
9/10 3/11 8/11 X12/11 X 7/12
Not Assessed
9/10 or 3/11 8/11 12/11 7/12 2/13 9/13 3/14 10/14
Not

Page 12 of 56

Case: 1:10-cv-02946 Document #: 346 Filed: 01/09/17 Page 13 of 56 PageID #:5269

Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction standards. CCDOC 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.

9/13 3/14 10/14 4/15 3/16 6/16 12/16

Assessed
9/10
3/11 8/11 12/11 7/12

G. 83k

DFM shall develop a policy on hazardous materials, in accordance with generally accepted correctional standards, and insure that all DFM staff is properly trained on the procedure.

CONCLUDED BY ORDER OF JUDGE KENDALL 6/22/15

G. 83l CCDOC shall provide and ensure the use of cleaning chemicals that 8/11 Not

sufficiently destroy the pathogens and organisms in biohazard spills.

12/11 7/12 2/13

Assessed
9/10 3/11

9/13

3/14

10/14

4/15

3/16

6/16

12/16

G. 83m CCDOC shall inspect and replace as often as needed all frayed and 8/11 3/11

9/10

cracked mattresses. CCDOC shall destroy any mattress that cannot 2/11

be sanitized sufficiently to kill any possible bacteria. CCDOC shall 7/12

ensure that mattresses are properly sanitized between uses.

2/13

9/13

10/14

4/15

3/16

6/16

12/16

Page 13 of 56

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Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 83n

CCDOC shall ensure adequate control and observation of all housing 8/11 9/10

units, including distribution and collection of razors and cleaning 12/11 3/11

supplies. All cleaning tools and hazardous chemical shall be

7/12

removed from housing areas after use.

2/13

9/13

3/14

10/14

4/15

3/16

6/16

12/16

G. 83o
G. 84 G. 84a

CCDOC shall ensure that Facility sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.
Sanitary Laundry Procedures

12/11 9/10 7/12 3/11 2/13 8/11 9/13 3/14 10/14 4/15 3/16 6/16 12/16

CCDOC shall develop and implement policies and procedures for

8/11 9/10

laundry procedures to protect inmates from risk of exposure to

12/11 3/11

communicable disease, in accordance with generally accepted

7/12

correctional standards. To limit the spread of communicable

2/13

disease, CCDOC shall ensure that clothing and linens returned from 9/13

off-site laundry facility are clean, sanitized, and dry.

3/14

10/14

4/15

3/16

6/16

12/16

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Substantial Compliance
Partial Compliance
Noncompliance

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Section

Language

G. 84b CCDOC shall ensure that inmates are provided adequate clean

3/14 3/11 9/10

clothing, underclothing and bedding, consistent with generally

10/14 8/11

accepted correctional standards, and that the laundry exchange

4/15 12/11

schedule provides consistent distribution and pickup service to all 3/16 7/12

housing areas.

6/16 2/13

12/16 9/13

G. 84c CCDOC shall train staff and educate inmates regarding laundry sanitation policies.

3/14 8/11 9/10 10/14 12/11 3/11

4/15 7/12

3/16 2/13

6/16 9/13

12/16

G. 84d CCDOC shall ensure that laundry delivery procedures protect

12/11 9/10

inmates from exposure to communicable diseases by preventing 7/12 3/11

clean laundry from coming into contact with dirty laundry or

2/13 8/11

contaminated surfaces.

9/13

3/14

10/14

4/15

3/16

6/16

12/16

G. 84e CCDOC shall require inmates to provide all clothing and linens for 9/13 9/10

laundering and prohibit inmates from washing and drying laundry 3/14 3/11

outside the formal procedures.

10/14 8/11

(* In the Monitor Report #V dated July 20, 2012; this provision was inadvertently recorded “substantial compliance.” The provision should have been recorded “partial compliance.”)

4/15 3/16 6/16 12/16

12/11 7/12* 2/13

G. 85 Food Service

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Substantial Compliance
Partial Compliance
Noncompliance

Section

Language

G. 85a G. 85b G. 85c G. 85d G. 85e

CCDOC shall ensure that all food service at the Facility is operated in 9/13 3/11 9/10

a safe and hygienic manner and that foods are served and

3/14 8/11

maintained at safe temperatures.

10/14 12/11

4/15 7/12

3/16 2/13

6/16

12/16

CCDOC shall ensure that all food service staff, including inmate

7/12 9/10

staff, must be trained in food service operations, safe food handling 2/13 3/11

procedures, and appropriate sanitation.

9/13 8/11

3/14 12/11

10/14

4/15

3/16

6/16

12/16

CCDOC shall ensure that the Central Kitchen and Division XI kitchen 2/13 9/10

are staffed with a sufficient number of appropriately supervised

9/13 3/11

and trained personnel.

3/14 8/11

10/14 12/11

4/15 7/12

3/16

6/16

12/16

CCDOC shall ensure that dishes and utensils, food preparation and 2/13 9/10

storage areas, and vehicles and containers used to transport food 9/13 3/11

are appropriately cleaned and sanitized.

3/14 8/11

10/14 12/11

4/15 7/12

3/16

6/16

12/16

CCDOC shall check and record, on a regular basis, the temperatures 7/12 9/10

in the refrigerators, coolers, walk-in-refrigerators, the dishwasher 2/13 3/11

water, and all other kitchen equipment with temperature monitors 9/13 8/11

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Substantial Compliance
Partial Compliance
Noncompliance

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Section

Language

to ensure proper maintenance of food service equipment.

3/14 10/14 4/15 3/16 6/16 12/16

12/11

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STATUS REPORT DATE OF STATUS REPORT: 6/28/16 PROVISION: C. MEDICAL CARE 53. Treatment and Management of Communicable Disease e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing. December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: The Department of Facilities Management (DFM) monitors and record the results of the negative pressure testing for the 18 isolation cells located on the third floor (3-E) of Cermak, along with the enunciator panel once each shift. The documentation is maintained in the DFM office located in the Cook County Courthouse. Work orders are submitted and appropriate repairs made anytime monitoring demonstrates non-compliance. Occupational and Environmental Hygiene Services at the Great Lakes Center for Occupational and Environmental Safety and Health at the University of Illinois, Chicago, conducts a full testing of the ventilation system annually. Copies of those reports are provided to the Chief Medical Officer of Cermak. Monitor’s Assessment: No change from the previous report. The pressure monitoring by DFM is included in their Preventative Maintenance Schedule and completed as required. This provision continues to be in substantial compliance. Monitor’s Recommendations: 1. No further recommendations. PROVISION: C. MEDICAL CARE 53. Treatment and Management of Communicable Disease f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems. December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
In mid-October DFM transitioned from the “Facility Wizard” work order processing system to the new cloud based work order management information system which is named “FAMIS”. The new system provides all users including Cermak real time tracking of work order completion and backlog. Cermak submits work order requests using the new system for both emergency and routine repairs. Scheduled preventive Maintenance is in the process of being loaded into the new system. Cermak’s Environmental Services Director and supervisory staff are trained and authorized to enter work order requests to DFM electronically. They continue to monitor the status of all Cermak’s work orders daily to assure timely completion of work orders.
Monitor’s Assessment:
Because of the transition to the new Environmental Services Director, the Monitor did not tour Cermak on the previous visit. The Monitor did tour Cermak on this visit and found it to be clean, with no maintenance issues for which a work order had not been submitted. As stated in the previous report, the new Environmental Services Director who began in late June formerly worked in a management role with DFM at the CCDOC complex and is very familiar with the work order system and the responsibilities for this position. Management staff at Cermak continues to report excellent response from DFM to quickly resolve any outstanding preventive and emergency work orders.
Monitor’s Recommendations:
1. No recommendations.
PROVISION: F. FIRE AND LIFE SAFETY
71. CCDOC and DFM shall work together to develop and implement a fire safety program and ensure compliance is appropriately documented. The initial Fire Safety Plan shall be approved by the fire prevention authority having jurisdiction. The Fire Safety Plan shall be reviewed thereafter by the appropriate fire prevention authority at least every two years, or within six months of any revisions to the plan, whichever is sooner. Fire safety and emergency procedures shall be standardized across divisions, to the extent possible given differences in physical plant and security levels.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
The interagency Fire Safety Committee, established shortly after the start of the monitoring, continues to meet monthly discuss and monitor implementation all fire and life safety policies and procedures. They review and assess all the fire safety and prevention systems including monthly safety inspections, fie investigations, elimination of flammables in housing units, fire drills, policies and procedures. They develop fire and emergency evacuation training material and conduct training.
CCDOC completed the review and issued a revised Fire Safety, Fire Emergency and Fire Evacuation Policy that replaces the Interagency Directive 64.5.30.0 from 2011. It includes the responsibilities for DFM for maintaining compliance with the Chicago Fire Code for smoke detectors, fire alarms, sprinkler systems, chemical storage areas, laundry facilities and maintenance areas/shops and to conduct and respond to all emergency repairs of fire and life safety equipment as outlined in DFM policy within 24 hours. Cermak has responsibilities for training of their employees and to respond to fires and fire alarms in accordance with their policies and to participate in the incident command structure.
The City of Chicago fire safety inspectors complete an inspection of CCDOC facilities annually. Scheduled by the fire safety committee, but unannounced fire drills are conducted regularly on all shifts for all divisions. When available, an inspector from the Fire Prevention Bureau, along with the responding fire station firefighters participates as part of their response training.
CCDOC maintains a designated fire safety administrator and designated fire safety/sanitation officer positions in all divisions on all including weekends and holidays. Fire Safety Training is provided as part of initial correction officer orientation program at the Training Institute located in Moraine Valley Community College.
The Fire Safety Interagency Agreement requires divisional Safety/Sanitation Officers to conduct weekly fire safety inspections of all housing, administrative, medical clinics, storerooms, maintenance rooms, classrooms, and common areas within their respective divisions to identify fire safety hazards and resolve them. CCDOC General Order 24.11.1.0 was revised to require these inspections. General Order 24.11.1.1 was issued on October, 3, 2014
Monitor’s Assessment:
As stated above, the new Fire Safety, Fire Emergency and Fire Evacuation Policy 402 is complete and has been authorized. The policy is awaiting review by the Chicago Fire Department and is
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expected to be completed before the end of the year, well within the six month requirement specified in the provision.
The Fire Safety Committee continues to provide the Monitor summaries of its meetings. Prior to the tour the Monitor reviewed the meeting summaries from August 17, September 15, October 20, and November10. The Monitor met with the Committee during the tour to review compliance with the fire and life safety provisions and discussed the fire drill assessments fire investigations, and emergency key system improvements. Cermak is once again actively participating in the Committee.
The Fire Safety Committee continues its formal reviews of all fire investigations. The reviews have resulted in several improvements to eliminate ignition sources as noted in the previous report. The provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. Obtain evidence of the review of the new Fire Safety Policy by the Chicago Fire Department as required.
2. Continue investigating all fires and fire drills to identify procedural or training improvements needed.
72. CCDOC shall develop and implement an evacuation plan for inmates and staff and ensure that comprehensive fire drills are conducted every three months on each shift. CCDOC shall document these drills, including start and stop times and the number and location of inmates who were moved as part of the drills.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Division specific Fire Safety and Emergency Plans that include detailed evacuation plans are complete and are reviewed by the Chicago Fire Department. It is only the new policy that needs review. The Interagency Fire Safety Committee continues to review the divisional plans, along with the division fire safety/sanitation officers to assure they remain current. The Committee has implemented a division specific fire evacuation and emergency key egress box training program to assure that when officers are assigned to a specific division, they are adequately trained in that division’s emergency egress key location, response and evacuation procedures.
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As in the previous Interagency Directive for Fire Safety, the new Policy 402 requires a minimum of quarterly fire drills for all divisions on each shift. They are required to be conducted in different locations of the division to practice evacuation procedures. The policy also requires the divisions to simulate obtaining emergency keys and include fire alarm, strobe and speaker activation in coordination with DFM. Drills are to be videotaped for review by the fire safety committee. The provision continues to be substantially compliant.
Monitor’s Assessment:
The Monitor did not witness any fire drills during the tour. However, CCDOC provided copies of several fire drill reports, along with the written fire drill analysis for August and September, 2016 completed by the Fire Safety Committee. The reviews were thorough and offered appropriate suggestions for improvements such as additional training.
Monitor’s Recommendations:
1. Continue to analyze fire drill videos, reports and summaries.
73. DFM shall ensure that the Facility has adequate fire and life safety equipment, including installation and maintenance of fire alarms and smoke detectors in all housing areas according to applicable fire codes. Maintenance and storage areas shall be equipped with sprinklers or fire resistant enclosures in accordance with City of Chicago Fire Code (13-76-010).
6/22/15 Concluded by Order of Judge Kendall
74. DFM shall ensure that all fire and life safety equipment is properly maintained and routinely inspected. DFM shall develop and implement a program related to the testing, maintenance and inspection of the Life Safety Equipment.
6/22/15 Concluded by Order of Judge Kendall
75. CCDOC shall continue to 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.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
The Security and Key Control Interagency Directive was issued effective January 1, 2012. It requires that each Division have a “red” emergency key access box located in the division’s control room. That box contains the key that opens a second box containing all emergency
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keys for all housing unit doors. The key box is locked and has a security seal that must be broken to gain access. The policy further requires that any time the seal is broken, including during an emergency, the Watch Commander be notified, an incident report completed, and an email sent to the Fire Safety Officer to replace the seal. Only a member of the Fire Safety Committee can re-seal the box.
All emergency egress keys are color coded and have a two-inch glow stick attached to the key ring. Restricted keys are those specifically assigned to designated personnel with the authority of the respective division superintendent or DFM’s Deputy Director/OEIV. The restricted keys are color coded differently than the egress keys and are specifically designated keys for the library, classrooms, recreation rooms, etc. Emergency access keys for DFM shops are stored in the emergency key box in the division where the shop or penthouse is located
CCDOC, as a result of the Fire Safety Committee investigation has recently installed color coded “zip ties” on each of the emergency key ring in addition to the glow sticks. The zip tie colors red , blue, white, black, green, yellow, orange, and lime green are systematically assigned for specific key and locks including exit doors to the outside, cells, stairwell doors, tier doors, dorm rear doors, officer area doors, and tunnel exit. The color scheme is consistent for all Divisions, simplifying officer training. An emergency key color chart is maintained in the emergency key box as an additional resource for staff.
The Fire Safety Officer is investigating the use of the same scheme on each of the locks which should provide even quicker access.
The CCDOC Training Academy is responsible to provide Egress box familiarization training to Correction recruits and for sworn officers during the annual in-service training. The Fire Safety Coordinator sends a quarterly egress key exercise to each division requiring all officers on all shifts to retrieve a set of egress keys from the egress key box and use those keys to open the interlock door, a cell door and an emergency stairwell. The officer then signs a log that they completed the exercise.
Emergency keys are accessed during all fire drills and are tested in the locks for the area of the drill.
Monitor’s Assessment:
As of this tour one set of all keys to DFM shops and penthouse rooms are now maintained in the emergency key box in all divisions where DFM maintains a shop. The fire safety committee recently developed an Egress Key Exercise for all correction officers. It was completed in March and April, 2016. CCDOC provided the Monitor with a copy of the memo
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dated June 8, 2016 requiring the Division Superintendents to complete the Egress Key Exercise and demonstrate completion through signature sheets requiring each officer to sign that they have completed the exercise in the Division or area they currently work. Prior to this tour CCDOC provided copies of the completed signature confirmation sheets egress key exercise for all divisions demonstrating completion of the exercise and compliance with the training component of the provision. The provision continues to be substantially compliant.
Monitor’s Recommendations:
1. Maintain the quarterly emergency egress key training.
2. Consider the same color coding of locks to match the color code scheme of the emergency keys.
76. CCDOC 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. CCDOC shall conduct and document random audits to test staff proficiency in performing this task on all shifts, at a minimum of three times per year. CCDOC shall conduct regular security inspections of all locking mechanisms. CCDOC shall communicate with DFM via the Work Order System regarding lock-related issues and maintenance.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Emergency keys for each division are stored in the division’s secured control room. All emergency keys are color coded as described in the previous provision and each ring has a glow stick attached that allows staff to easily identify a specific key when vision may be impaired because of smoke, fire or loss of lighting. The Fire Safety Committee explained that on every shift, the officer assigned to the unit or tier inspects all locking mechanisms and reports any issues through the DFM work order system. The Fire Safety Committee reviews the damaged lock work order log each month. They have also implemented an “Egress Key Exercise for each Division on all shifts by all personnel as reported in the provision 75. Egress key accessibility and process are also included as part of the routine unannounced fire drills as described above.
CCDOC utilizes the work order system to report damaged locks and provided trend analysis showing the time DFM takes to repair the locks. All locks for all cells and door are checked on each shift by the tier officer.
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Monitor’s Assessment:
CCDOC provided the “Damaged Lock Work Order Log” for June-November, 2016. The fire safety committee produced a trend report showing a 47% reduction in damaged locks over that period. CCDOC reported only one monthly increase in the incidents of damaged locks and that was in October, 2016 (77 damaged locks) primarily because of excessive inmate damage in Division 11. Another trend report was provided demonstrating a 73% reduction in the average number of days from submission to closure of work order repairs for damaged locks from 15 days in February to four days in October, 2016.
CCDOC provided copies of fire drill reports for all division on all shifts documenting that emergency keys were accessed and used during those drills. On this site visit the Monitor noted only one incident in Division VI where a secondary emergency evacuation exterior door could not be opened using the key. The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
77. DFM shall develop and implement an annual preventative maintenance program concerning security devices such as doors locks, fire and smoke barrier doors, and manual unlocking mechanisms to ensure these devices function properly in the event of an emergency.
6/22/15 Concluded by Order of Judge Kendall
78. CCDOC shall implement competency-based testing for staff regarding fire and emergency procedures.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Revised CCDOC Policy 402, Fire Safety, Fire Emergency, And Fire Evacuation replaced Interagency Directive 64.35.30.0 Fire Safety, Fire Emergency, and Fire Evacuation. The new policy establishes that the Training Academy is responsible for fire safety training for the Department of Corrections recruits and for sworn members during the annual in-service training. At a minimum the training shall include fire extinguisher usage, egress box familiarization, review of emergency routes, fire suppression, and divisional fire and evacuation plans. Designated safety officers (FSSOs) shall receive training semi-annually and become well versed in the fire safety, emer5gency and evacuation plans for the Department. The training
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shall include report writing, conducting a fire inspection, and overview of policy and procedures in addition to the training for sworn members. Safety Officers (SSOs) are assigned on all shifts in all divisions including weekends and holidays. Employees of both DFM and Cermak are required to be trained by the respective agencies in accordance with their fire safety and evacuation plans.
CCDOC created an interactive Fire Safety Training PowerPoint presentation. It follows the procedures specified in the Fire Safety Policy. It is interactive in that officers are required to answer questions about a topic before being permitted to move forward to the following module. Additionally the Safety Officers must successfully complete a written proficiency exam for fire safety with a minimum passing score of 80%.
Monitor’s Assessment:
The competency based fire and emergency evacuation safety officer proficiency exam was initiated in August, 2011. For this site visit CCDOC provided sign-in logs for Safety Officer training held August 18 (2 classes) August 19, and November 23. Training for 2016 was also conducted in April as stated in the previous report and it demonstrates that there is a minimum of one trained safety/sanitation officer on every shift for each occupied Division. In most, there are several on each shift. CCDOC provided the Monitor with Power Point presentations for “Fire Safety Training for Supervisors”, and “Fire Safety Training” for staff. The presentations are thorough, well organized, and follow the provisions of the General Order for Fire Safety. The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations
79. CCDOC shall promptly notify DFM of all electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC maintains written procedures requiring prompt submittal for all work order requests when maintenance issues are identified including electrical hazards. Specifically for electrical hazards, both DFM management and the CCDOC work order coordinator monitor work order backlog weekly. CCDOC is fully integrated with the new DFM “FAMIS” cloud based work order system.
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Monitor’s Assessment:
CCDOC provided a log of all work order requests for electrical repairs from April through November, 2016. In the eight months there were 52 work orders filed with an average of 6.5 per month. Of those approximately 26 were in inmate accessible areas. Repairs were made on a range of 1-15 days depending on parts and priority. During this site visit, the Monitor toured the Central Kitchen, laundries, housing units in Divisions 3 annex, Cermak, 4, 6, 9 and 10. Only one missing cover plate was observed in Division 4 Tier P. Since the replacement lighting project, the number of work orders for exposed wires and broken fixtures has dropped significantly primarily because inmates no longer have access the wires in the fixtures. As reported in the previous recent fire investigations identified inmates are now using the aluminum foil lids from applesauce containers to create a spark from outlets for televisions in the housing units. Applesauce has been removed from the menu. DFM continues to encase the televisions, electrical cord and the outlet to prevent inmates from being able to access them to create a spark. The Monitor observed the new encasements in Division 9 and 10 on this tour. The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
80. DFM shall promptly repair all known electrical hazards, including maintenance and repair of electrical outlets, devices, and exposed electrical wires and will document repairs by the Work Order System.
6/22/15 Concluded by Order of Judge Kendall
81. CCDOC shall ensure that combustibles are controlled and eliminate highly flammable materials throughout the facility and inmate living areas (e.g., inmates’ use of paper bags as trash receptacles, ripped fire-retardant mattress covers, improvised cell light covers, blankets on cell floors, and improperly stored and labeled flammable liquids and other chemicals
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
General Order 24.11.1.1 “Sanitation, Fire Health and Life Safety Plans and Reporting” is the CCDOC Master Sanitation Plan. Division specific sanitation plans are revised as appropriate to
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the General Order. The replacement program for new lighting fixtures has also eliminated the incandescent bulbs inmates used to block light.
Inmates are required to maintain all personal belongings and commissary in their personal property bags. Inmates housed in cells are permitted one paper bag per person for trash from commissary that is required to be emptied daily. CCDOC has developed a “Combustible Material Awareness” PowerPoint presentation to train correction officers that includes photographs of combustibles found during fire investigations.
DFM controls the storage of flammables in their shops by maintaining them in designated secure fire resistant cabinets. Additionally Chair of the Fire Safety Committee sends a fire safety bulletin to all divisional superintendents and their respective Assistant Executive Directors regarding wick ignition and sources to make them aware of recent incidents and also know what officers need to observe during cell inspections.
DFM has completed the color-coded map and inventory of all flammable and hazardous chemicals and provided it to CCDOC division safety officers and Safety Administrator. So within each division, there is an up-to-date inventory of all flammables being stored in that specific division. The inventory is maintained by DFM and is readily available to first responders in case of an emergency.
Monitor’s Assessment:
The Monitor toured housing units in Divisions Cermak, 3-Annex, 4, 6, 9, and 10. In all instances housekeeping continues to improve and inmates are maintaining commissary in their assigned personal property bags. The amount of flammable material exposed in the cells is significantly reduced. None of the fire investigations provided prior to this tour involved the use of paper bags as fuel. In all Divisions visited, the Monitor did not observe any torn or damaged mattresses. Consistent enforcement from tier officers and supervisors to limit the amount of flammable materials within the cells continues to be a key to assure the expectations are met. Additionally Superintendents and Assistant Executive Directors need to be more vigilant when touring housing units.
The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
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82. CCDOC 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.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Revised CCDOC Policy 402, Fire Safety, Fire Emergency, And Fire Evacuation replaced Interagency Directive 64.35.30.0 Fire Safety, Fire Emergency, and Fire Evacuation. The policy establishes that all CCDOC employees must receive training and become well-versed in the fire safety, emergency, and evacuation plans of the department and its divisions. This includes safety officers. (Note: In the divisions there are designated and trained “Safety/Sanitation Officers” that are equivalent to the term “safety officers” identified in the provision requirement above.) Further, the policy explains that “Communication among and between CCDOC, Cermak, and CCDFM employees is key in assuring a safe facility, and all shall work together to implement this directive.”
The revised policy 402 establishes semi-annual training of safety officers as described in the narrative of Provision 78 above. It includes training on basic housekeeping emergency preparedness, applicable fire codes and the use of fire extinguishers and other emergency equipment. The Safety Officers are trained to complete and submit a weekly fire safety inspections report for all housing, administrative areas, medical areas, storerooms, maintenance rooms, classrooms and common areas within their respective divisions. Monthly the second shift safety officer is required to review the weekly fire safety inspection reports noting all uncorrected deficiencies and submit it to the Superintendent with a copy to the Fire Safety Coordinator. Any fire safety deficiencies not corrected within 30 days are submitted to the DFM coordinator. CCDOC maintains an active list of all designated safety officers showing at least one on duty on all shifts including weekends and holidays for all divisions.
The training of safety/sanitation officers is currently provided by the CCDOC designated Safety Administrator, using the video of one of the courses previously conducted by the Chicago Fire Department. Following the training, safety officers are required to pass a written proficiency examination. CCDOC has also developed a “Fire Extinguisher Training” PowerPoint that is thorough tutorial on the types of extinguishers, operation, and firefighting rules.
Monitor’s Assessment:
As stated in Provision 78 CCDOC provided sign-in logs for Safety Officer training held August 18 (2 classes) August 19, and November 23. Training for 2016 was also completed in April as
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stated in the previous report and it demonstrates that there is a minimum of one trained safety/sanitation officer on every shift for each occupied Division. In most cases there are several on each shift. CCDOC provided copies of sign-in sheets, along with a list demonstrating that there are safety officers on every shift in every Division housing inmates. The list also shows assigned safety officers for the laundry, kitchen, DFM, and Cermak infirmary. CCDOC provided a copy of the Power Point training program used for Safety/Sanitation Officers and Supervisor assigned to each Division. This is in addition to their divisional safety manuals that were issued prior to the previous tour. This provision continues to be in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations
PROVISION: G. SANITATION AND ENVIRONMENTAL CONDITIONS
83. Sanitation and Maintenance of Facilities
a. DFM shall maintain an adequate written staffing plan and sufficient staffing levels to provide for adequate maintenance of the Facility.
6/22/15 Concluded by Order of Judge Kendall
83. Sanitation and Maintenance of Facilities
b. CCDOC shall revise and implement written housekeeping and sanitation plans to ensure the proper routine cleaning of housing, shower, and medical areas, in accordance with generally accepted correctional standards. 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.
June, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC General Order 24.11.1.0, and division specific Sanitation Plans have been recently revised. The revisions reflect improved practice and include specific sanitation plan and schedules for all housing and common areas of the divisions and require documented housekeeping completion logs signed by the sanitation officer, inspection reports, a deficiency plan for corrective actions and requisition procedures for cleaning supplies.
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Division designated safety/sanitation officer for each division is trained by the CCDOC Sanitarians on safe and effective cleaning and disinfecting procedures. In the General Order Watch Commanders are responsible for reviewing the completed Daily Inspection Completion Forms from each of the living units and submitting a weekly summary report. The Support Services Superintendent and Sanitarians receive and review the weekly summary of the sanitation log from each of the divisions. The divisional sanitation plans mandate that safety/sanitation officers observe the cleaning and disinfection of cells, dayrooms, toilets and shower facilities. Since the divisional sanitation plans became effective, the Sanitarians continue to conduct unannounced inspections of living units within all divisions.
CCDOC recently implemented a toll free 24-hour inmate telephone line for inmates to submit living unit issues. It is currently operating in Division 2 dorm 4, and Divisions 4, 6, 10 and 11. The plan is to expand it to Division 4, 9, 14 and the remaining dorms in Division 2. The purposed is to improve overall living conditions for detainees, reduce lag time for submission of work orders, and reduce the number of livening condition grievances. It is another opportunity for detainees to get issues remediated.
CCDOC implemented an incentive for housing unit cleanliness and order by providing microwave ovens to those living units where the rules are being followed. This process established accountability from both inmates and officers to improve and maintain the level of cleanliness and order of the living units as well as common areas including classrooms, maintenance closets, and tunnels. Improvement in cleanliness in those housing units where microwaves had been provided is generally significant when compared to those units where they are not available.
Cermak Environmental Services has developed a written policy and a new electronic sanitation schedule that establishes procedures for cleaning and disinfection of all areas for medical and mental health inmates and each of the division specific dispensaries. Its purpose as stated is to, “To ensure through collaborative departmental efforts of sanitation, prevention, maintenance, and education that all areas under Cermak Health Serv ices” (CHS) authority shall be maintained clean, disinfected, well organized, and in good repair.” It establishes formal housekeeping procedures, schedule, and expectations for the building service workers responsible for completing the all cleaning and disinfection. It includes a daily “monitoring” program conducted by building services supervisors to be submitted to the Environmental Services Director on an electronic database. Environmental Services has provided training of the building service workers and supervisors.
Cermak has also instituted “environmental rounds” done weekly and over the course of a month assess all divisional clinics, the infirmary and emergency room.
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The housekeeping policy requires daily inspections completed by the tier officer on each shift. The form requires the deputy to note any issues including the need for work orders, cleanliness issues, etc. Monitor’s Assessment: For this tour the Monitor assessed housing units in Divisions 3-Annex 4, 6, 9, 10, and Cermak. Cleanliness was much improved since the previous tour. The inmate showers in all Divisions visited were clean; clearly the frequent use of the power washing equipment that was purchased for each division has had a positive outcome. In Division 3-Annex the Monitor observed excess peeling paint on the shower walls and floors of virtually every shower in both pods visited. DEM is in the process of scraping and repainting all showers. The Monitor suggests DFM and CCDOC set up models of shower wall surfaces using various paints and/or sealers. The models would be washed using different pressures to determine the most effective pressure that is able to clean soiled surfaces and not damage the paint. Repainting in #-Annex is needed at least annually. This is disruptive to housing units as inmate need to be relocated for several days for the paint to seal and for odors to dissipate. The provision is substantially compliant. Monitor’s Recommendations: 1. Continue to enforce sanitary housekeeping practices in the housing units. Assure
supervisors are requiring compliance from the officers. To expect inmates to comply with inmate rules when enforcement by deputies, supervisors, commanders, superintendents, and Assistant Executive Directors is not practical and fair for all. 2. Assess the need for additional bags for inmates to store shower towels, shoes, shampoo etc. and assure that whatever you choose is consistent within all Divisions. The type, number and use of personal property bags should be consistent throughout all Divisions. 3. Review the need for providing additional drinking water sources within the housing units, and if provided assure there is a process for rotating dispensing coolers that include a process to clean and disinfect between uses.
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83. Sanitation and Maintenance of Facilities
c. DFM 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.
6/22/15 Concluded by Order Judge
83. Sanitation and Maintenance of Facilities
d. CCDOC shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting, and ventilation problems.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update: As stated earlier in this report DFM replaced the “Facility Wizard” work order tracking system with a cloud-based system “FAMIS”. Just like the former system, it too interfaces with both CCDOC and Cermak. It has been operational since mid-November, 2016.
General Order 24.9.9.0 established an inspection protocol for designated officers in each Division to initiate work order requests. The food service contractor also has access to submit work order requests through Support Services staff. The CCDOC Sanitarians can also submit work order requests. The Sanitarians have created a Power Point presentation for training living unit officers demonstrating what constitutes a needed plumbing, electrical and emergency issues.
As a result, work orders from CCDOC staff can be submitted as soon as any issue is identified. The use of the 24 hour hotline for emergency repairs assures that emergency maintenance repairs are forwarded to appropriate DFM trades to quickly respond to these typically within minutes.
Monitor’s Assessment:
Other than the new system, there are no changes since the previous report. The Monitor noted that when plumbing issues were observed during the tour, in virtually every case, the safety officer or Commander was able to demonstrate that a work order had been previously submitted to DFM. Each division maintains a spreadsheet listing the outstanding work orders. The spreadsheet is updated at least weekly. Universally, housing officers and supervisors stated they are pleased with the timely response from DFM to complete repairs. DFM also provided a trending chart demonstrating that the number of work orders not completed within
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30 days continues to be very low. As of December 5, 2016 the number of open work orders for plumbing was 47 and 8 electric. They are due to primarily to parts procurement. The provision continues to be in substantial compliance. Monitor’s Recommendations: 1. No further recommendations.
83. Sanitation and Maintenance of Facilities e. DFM shall ensure adequate ventilation throughout the Facility to ensure that inmates receive an adequate supply of air flow and reasonable levels of heating and cooling. DFM staff shall review and assess compliance with this requirement on a daily basis for automated systems and on and annual basis for non-automated systems.
6/22/15 Concluded by Order Judge Kendall
83. Sanitation and Maintenance of Facilities f. CCDOC shall notify DFM of any visible obstructions to the ventilation system.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: DFM staff clean and/or replace blocked or dirty vents based on work orders entered by CCDOC or Cermak. Monitor’s Assessment: CCDOC provided a log of 36 work orders entered for the months of July through November, 2016. The Monitor observed one dirty vent in Division 4, Tier P and one blocked vent in Division 6 cell 2117 where the inmate blocked the vent to reduce cold air. Correction officers generally seem to be effective in not permitting inmates to block air flow in the cells. The number of blocked vents went down significantly once CCDOC eliminated use of Styrofoam trays from meals that were being used to block air movement in the cells. Blocked vents are no longer a significant systemic issue within any CCDOC division. This provision remains in substantial compliance. Monitor’s Recommendations: 1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
g. Cook County shall ensure adequate lighting in all inmate housing and work areas.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
DFM maintains responsibility for assuring adequate lighting throughout the CCDOC complex. They completed the capital project to replace or retrofit all lighting with secure fixtures that would prevent inmate abuse and improve energy efficiency within the living units within all divisions in 2013. Lack of adequate and secure lighting in housing and work areas continues not to an issue within any inmate housing units within CCDOC. Fixtures requiring the use of unprotected Incandescent bulbs are no longer used in inmate cells, dayrooms or showers.
Monitor’s Assessment:
Adequate and secure lighting is not a systemic issue in any division visited on this tour. That said, burned out lights will always continue to occur. However they are replaced by DFM using the work order system. CCDOC provided a list of work orders entered for light bulb replacement from July through October. DFM completed most within a few days. Because of the sheer number of fluorescent tubes throughout the campus, many work orders are entered each month. CCDOC is vigilant in filing the work orders. The provision remains substantially compliant.
Monitor’s Recommendation:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
h. CCDOC shall ensure adequate pest control throughout the housing units, medical units, RCDC, RTU, and food storage areas. CCDOC shall maintain a contract for professional exterminator services for each division, food services areas, and the Cermak hospital. Services should provide for routine pest control spraying and additional spraying as needed.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC maintains a contract for pest control services for all facilities with the exception of Cermak. Cermak maintains a separate contract their facility. The CCDOC contract requires the
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pest control technician be onsite 5.5 hours per day. The current contractor provides CCDOC a map showing the location of all traps, and completes comprehensive inspection following an “Integrated Pest Management” approach. The contractor is required to complete a floor drain cleaning procedure a minimum of twice per year to prevent insect eggs and larvae from developing, and provide a 24 hour response time for complaint response. They provide a quarterly trend reports, tracking insect and rodent activity for all divisions, along with electronic reports of their inspections and any recommendations for improved sanitation and/or maintenance repairs.
CCDOC maintains a “pest control hotline” for officers to report any pest activity. Steps to prevent pest issues and infestations are reinforced at the training academy for all correction officers.
Monitor’s Assessment:
CCDOC provided a copy of Pest Identification summary for the third quarter of 2016, along with the trend analysis completed by the CCDOC Sanitarian. The report includes a monthly list and a quarterly summery spreadsheets showing by division the number of pest catches including mice, three types of cockroaches, ants, fruit flies, drain flies, gnats and silverfish. They also provided pie charts showing both interior and exterior catches for rodents. For example the most recent report noted that of the 97 mice caught 64% were caught in external traps a 7% increase from the first quarter report. The areas that have the most significant rodent activity are Divisions 4, 6, and 11. Ants appear to be an isolated issue in Division 2 dorm 2 and Division 9. German cockroaches are a problem in Division 10. Both are significantly improved from the previous report. The Monitor continues to suggest that the trend analysis and summary should be expanded to 12 to 18 months to provide CCDOC management with seasonal data over a period. That information would be far more useful to demonstrate improvement or identify areas where modifications to the pest plan are needed. Also the reports need to be tier and dorm specific to identify specifically where within a division pest issues are prevalent including the floor and the specific tour. This will be valuable when measuring improvement or identifying specific problematic areas.
On this tour the isolated pest issues identified in the previous report continued in Division 4 tiers P and Q and in Division 6 C and D. The Monitor suggested a comprehensive assessment be made to identify internal building penetrations and assure that they are sealed. In Division 4 the mice may be in the wall supports and the only way to contain them will be to seal all penetrations. In Division 6, the problem appears to be a non-functioning door threshold in the doors that lead to the staircase. The pest control contractor should be identifying problem areas and providing recommendations to prevent access. This will provide the Sanitarians with
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much better data to conduct comprehensive inspections to identify both the access points and the cause of the problem such as excess exposed food, poor housekeeping and allow for effective corrective action. This same enhanced reporting should also be used where excessive insects are used.
In summary the provision remains “substantially compliant.” The two areas identified are isolated and are not representative of the entire complex, which have only limited trappings both for insects and rodents. That stated, the Monitor suggests that CCDOC address specific areas where several complaints from either inmates or staff are received. It would be helpful if supervisors, commanders, superintendents, assistant executive directors would ask inmates about pest activity when visiting tiers. The Monitor also suggests that CCDOC Sanitarians obtain an aerosol “flushing agent” such as “Mr. Inspector” to be able to quickly respond and verify insect activity such as ants or cockroaches.
CCDOC should track and document inmate complaints from the hot line to monitor trend activity and make sure areas of concern are quickly and effectively treated.
Monitor’s Recommendations:
1. Document the pest control summary and trend analysis over a longer period such as 12-18 months to provide useful data to measure performance by Divisions/floors, and tiers for both insects and rodents.
2. Document and track pest complaints from the hotline by Division and tier.
3. Review with the pest control contractor the need for a more comprehensive report identifying the specific areas within Divisions where pest activity is increasing.
4. Obtain and use pest flushing aerosol to be able to quickly verify insect activity in housing units so the contractor can more effectively treat as needed.
83. Sanitation and Maintenance of Facilities
i. CCDOC shall ensure that all inmates have access to needed hygiene supplies.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC implemented General Order 24.11.6 with an effective date of March, 2014. It requires that upon intake, employees shall issue inmate basic hygiene supplies including soap, toothpaste, toothbrushes, and as appropriate sanitary pads. Weekly, the safety/sanitation
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officer makes rounds to each housing unit to replenish inmate supplies of tooth brushes, toothpaste, and toilet paper as needed. Detainees needing additional supplies during the week only need to notify the housing unit officer on any shift. CCDOC tier officers maintain logs that record the inmate’s name, date of request, type of hygiene item requested, and a box to check when the requested item was provided. CCDOC is in the process of creating the tracking to an electronic format rather than a manual log. The current logs demonstrate that the detainee received needed supplies.
Monitor’s Assessment:
CCDOC Compliance Team has completed a formal audit of the Inmate Hygiene Policy. The audit revealed that the officers were distributing hygiene supplies (toilet paper, soap, and toothpaste) every week to all detainees whether or not the inmate needed them. The inmate can still request additional supplies as needed. However, there are some delays apparently because the sanitation officer may not replenish the supplies to the tiers promptly. As a result, the Divisions were not able to maintain an adequate supply of replacement items as specified in the policy (One and one half times the number of inmates housed there.) Questioning detainees, the Monitor heard a few isolated complaints from detainees, but clearly not enough to be a systemic issue. As a result, the provision remains substantially compliant. However, CCDOC needs to clarify the procedure to assure adequate replacement supplies are available on the tiers.
Monitor’s Recommendations:
1. Modify the procedures to assure sanitation officers provide timely replenishment of hygiene supplies to the tiers.
83. Sanitation and Maintenance of Facilities
j. CCDOC shall develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials, in accordance with generally accepted correction standards. CCDOC 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.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
Biohazardous waste from Cermak’s medical facility and the medical and/or dental clinics in the divisions is the responsibility of Cermak, not CCDOC. Biohazardous waste in Cermak is securely stored and placed in red bags for daily pick up by designated Cermak staff. Cermak maintains a contract for collection and final disposal of the waste.
For biohazardous waste from living units or laundry, the supply room in each division maintains a supply of biohazardous spill kits. They are replaced as needed through Support Services. CCDOC policy does not permit inmates to clean bio-hazardous spills. The blood-borne Pathogen Decontamination General Order was authorized in January, 2013. Support Services Sanitarians use a Power Point training presentation for biohazardous waste handling and cleanup that is now provided to all sanitation officers. There is a written syllabus for bloodborne Pathogen clean-up training. Cermak teaches the blood-borne pathogen training at the Academy and during in-service.
Monitor’s Assessment:
There is no change from the previous report. The kits include personal protective equipment (PPE) for response staff has well as clean-up supplies. The warehouse maintains a supplemental supply to replenish the divisional supplies. CCDOC staff has trained all safety/sanitation officers on all shifts the safe response procedures. The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
k. DFM shall develop a policy on hazardous materials, in accordance with generally accepted correctional standards, and insure that all DFM staff is properly trained on the procedure.
6/22/15 Concluded by Order of Judge Kendall
83. Sanitation and Maintenance of Facilities
l. CCDOC shall provide and ensure the use of cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
CCDOC dilutes concentrated chemicals following the chemical manufacturer’s specifications from the central supply room located in Division 5 and distributes them daily to the Divisions as requested. By centrally controlling the dilution and following the chemical manufacturer’s directions, the Divisions only receive properly diluted cleaning and disinfecting chemicals needed for routine cleaning and sanitizing of floors, toilets, lavatories, showers, etc. and effective cleaning and sanitizing surfaces from biohazard spills.
The chemicals include a general purpose cleaner, disinfectant, glass cleaner; stainless-steel cleaner, deodorizer, and bleach along with a supply of labeled spray bottles and labels. Only the designated floor care team has access to the cleaning chemicals used for floor care including floor stripper, floor wax, floor cleaner, and floor sanitizer Mop heads, mop sticks, vacuum, power washer brooms, dust pans and squeegees, along with buckets brushes, Tyvec suits, vinyl gloves, garbage bags and eyewash stations are all available through the warehouse.
Training for inmate workers and CCDOC sanitation officers on the safe and effective use of cleaning is taught by the Sanitarians. Training is provided to inmate workers assigned the responsibility of cleaning cells, showers, toilet facilities, dayrooms, classrooms, tunnels, and all administrative areas. These are two-hour classes daily, for one week. Each person that takes the class and successfully passes a written test is presented with a certificate of completion.
Tier officers provide Inmates with diluted chemicals to clean their respective cell sinks, toilets, and floors. “Sanitation kits” (plastic crates)have been distributed to each living unit to be used for inmate mattress cleaning and daily cleaning done by inmates. The crates include one spray bottle of general purpose cleaner, a spray bottle of disinfectant, two brushes (one for touch surfaces and one for toilets), four rags and an instruction card. Kits are now included in the count clearing process and the tier officer is responsible to assure inmates do not misuse the chemicals. The sanitation officer assigned to the 11pm to 7am shift is responsible to collect and restock the kits to the tiers.
Monitor’s Assessment:
There has been no change since the previous report. This provision continues to be substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
m. CCDOC shall inspect and replace as often as needed all frayed and cracked mattresses. CCDOC shall destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. CCDOC shall ensure that mattresses are properly sanitized between uses.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Mattresses are replaced as needed throughout the divisions when they become no longer cleanable or beyond repair. Each division maintains a small surplus of mattresses and more are available from Central Supply, if needed. When medically ordered, detainees assigned to Cermak are provided pillows and pillowcases or an extra mattress. Each division has a designated clothing and bedding supply room and maintains written procedures to inspect, clean, disinfect, and repair or replace mattresses before they are provided to incoming inmates. The room has designated areas for separate storage of clean and soiled mattresses. The soiled mattress is removed from the cell when an inmate is moved or discharged and taken to the designated storeroom within the respective division, inspected for damage, and if not damaged it is cleaned, disinfected, and safely stored. A trained inmate worker supervised by the supply room deputy is used. The mattress is allowed air-dry and returned to the cell or dormitory for use or stored until needed by the tier. Detainees are also permitted clean their mattress during scheduled daily cleaning utilizing the sanitation kits described above.
Hospital mattresses within Cermak are cleaned and disinfected within the cell or dormitory anytime an inmate is transferred or discharged. Cermak’s sanitation policy, formally establishes the procedure for cleaning and disinfecting them.
Monitor’s Assessment:
On this tour, as in recent past tours, the Monitor did not identify any mattresses in need of repair or replacement. All mattresses observed were well maintained with no tears or excessive wear. The Monitor did not receive any complaints from inmates regarding mattress issues. Staff reported the warehouse maintains an adequate supply of replacement mattresses.
Monitor’s Recommendations:
1. No further recommendations.
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83. Sanitation and Maintenance of Facilities
n. CCDOC shall ensure adequate control and observation of all housing units, including distribution and collection of razors and cleaning supplies. All cleaning tools and hazardous chemical shall be removed from housing areas after use.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC established General Order 24.11.7.0, Inmate Razor Distribution Effective March, 2014. Razors used throughout CCDOC are color coded by division. The CCDOC Assistant Executive Director (AED) of Special Projects is responsible for maintaining inventory of disposable razors and assigning designated staff to issue razors to each division. Each division’s Watch Commander is required to assure accuracy of the inventory and designate employees on each shift to verify the number of disposable razors on hand before distribution and upon their return form the inmates. Divisions are issued two biohazard waste containers with disposable plastic liners; one used to transport unused razors and one for collecting and returning used razors. The date and amount of razors are tracked in a “Disposable Razor Logbook” signed by the officer accepting the razors. Used razors are placed in the red biohazard container designated for “used” razors and returned to the AED for Special Projects’ office for safe disposal. No razors are maintained in the housing tiers or dormitories. All razors, used and unused, are audited daily to assure complete retrieval. If a discrepancy is identified, an incident report is generated. Razors are available for use by inmates on the 11pm to 7am shift Monday through Friday with the exception of holidays.
General Order 2.4.11.11.1, Sanitation, Fire and Life Safety Plan and Reporting Part D, addresses chemical distribution and return. Part E requires chemicals to be inventoried at the beginning and end of each shift.
Monitor’s Assessment:
For this tour CCDOC provided copies of the missing razor blades report and copies of all ten incidents that occurred from July-November, 2016. There were ten incidents nine of which involved one blade and one involving ten blades. The ten blade incident and two of the one blade incidents were miscounts in the razor supply rooms and the blades never involved detainees. The six of the seven blades were flushed down the inmate’s toilet and one was a missing blade that was never recovered. Incident reports were prepared for each and searches were conducted. For the missing 10 blade incident, CCDOC conducted a formal case review
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that resulted in an incident summary report describing how the ten blades were identified and located.
During the tour, the Monitor observed several daily distribution and return logs for chemicals as well as the daily/shift chemical inventories at two divisions. In all cases the inventories matched the actual counts and logs demonstrated no missing chemicals. Staff interviewed stated the correct process for investigating missing chemicals. Sanitation tools are returned to the janitorial supply closets at the end of each shift at all facilities.
The provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
83. Sanitation and Maintenance of Facilities
o. CCDOC shall ensure that Facility Sanitarians receive training from a relevant state, national, or professional association with emphasis on assessment of environmental health practices and emerging environmental issues in correctional settings. Facility Sanitarians should also have training on and access to testing equipment to ensure sanitary conditions.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC employs two full time Registered Sanitarians, who report to the Superintendent of Support Services. Both Sanitarians are active participants for all areas of the consent agreement involving environmental and safety issues including chemical control, sanitation, laundry, food service, and fire and life safety including training of both deputies and inmate workers, inspections, investigations and special projects. They actively participate in the review and revision of General Orders for these areas, along with developing and providing specific training programs to correction and civilian staff, and detainees. CCDOC provides them with and they regularly use measuring and testing equipment to monitor sanitation, temperatures, etc. They continue to research specific environmental issues such as pest control trends, food service, laundry, sanitation, maintenance, biohazardous materials, etc. They conduct independent sanitation audits, both for corrections and Cermak which has resulted in modification and improvements to training programs, enhanced follow up work and objective counsel with both corrections and coordinating efforts with Department of Facilities Management.
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They meet regularly with the contractor for food service, pest control, division superintendents, CCDOC management, Cermak, and DFM to assess and resolve issues. As part of their inspections, they regularly speak with both inmates and staff to identify issues that need resolution. They have an integral role in the implementation and monitoring of several CCDOC policies relative to sanitation and provide direction to the divisional sanitation officers. They have trained all divisional sanitation officers on correct cleaning procedures to assure continuing effective cleaning and sanitation. CCDOC is fortunate to have selected two outstanding Sanitarians who understand institutional environmental health, along with unique correctional issues and that are able to interpret and find solutions to protect the safety and health of both inmates and fellow employees.
Monitor’s Assessment:
CCDOC continues to maintain two environmental health positions who work may work on different shifts due to a wide variety of issues and services. Both Sanitarians participated in the tour. They regularly speak with detainees and assist correction officers helping both to understand the public health significance for specific policies and procedures, along with the impact of not following them correctly. Their commitment and their technical and communication skills have added considerable value to solve sanitation and safety issues in the divisions. Considering the increasing responsibilities and assignments, CCDOC needs to assess the need to provide one additional Sanitarian that may be assigned to a separate shift. This provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
PROVISION: G. SANITATION AND ENVIRONMENTAL CONDITIONS
84. Sanitary Laundry Procedures
a. CCDOC shall develop and implement policies and procedures for laundry procedures to protect inmates from risk of exposure to communicable disease, in accordance with generally accepted correctional standards. To limit the spread of communicable disease, CCDOC shall ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and dry.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
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Status Update:
CCDOC operates laundries in Division 4, 5, and 9. The Division 5 laundry is the central laundry for the complex and operates on three shifts daily. The Division 4 laundry handles the female detainees housed there and the female laundry from Cermak and Division 8 (RCDC). The Division 9 laundry is used for additional capacity as a back-up in case of equipment breakdowns in Divisions 4 and 5 facilities. The food service contractor operates a separate laundry to clean inmate worker uniforms and kitchen laundry. No laundry is transported to an off-site laundry.
CCDOC authorized General Order 24.11.3.0 effective March 7, 2014. It establishes the responsibilities assigned to the Laundry Unit Watch Commander and outlines the necessary training requirements for both employees and inmates assigned to the laundry units addressing safe sorting, washing, drying, and folding procedures and appropriate sanitation precautions necessary to be taken to assure that clean laundry is never cross-contaminated with soiled laundry. The Laundry Watch Commander, in turn, is responsible to train inmate workers on the procedure, sanitation, and the use of personal protective equipment (PPE).
The General Order requires all inmates to exchange soiled uniforms, towels and bed linen according to the posted schedule and strictly prohibits inmates from washing and drying clothing or linen. Personal laundry is collected from inmates twice each week on a schedule posted in each housing unit. Once cleaned, it is returned typically within the same shift from when it was collected. Living unit officers who observe clothing and linen being washed by inmates are expected to confiscate all such items and issue clean, dry clothing and linens and initiate an Inmate Disciplinary Report.
The Central laundry in Division 5 consists of five 150-lb Unimac washers and five 170-lb Unimac dryers. The Division 4 laundry consists of one Speed Queen 40 lb. washer and one 40 lb. dryers. The kitchen has one washer and one dryer.
Laundry chemicals used in all washers, including bleach, detergent and sour, are electronically dispensed. Laundry chemicals used are currently purchased from Ecolab. They include Ecostar Builder C detergent, Ecostar Destainer (Bleach), and Ecostar Sour (a pH adjusting chemical) to prevent skin irritation and fabric browning. Safety Data Sheets (SDSs) for all laundry chemicals are posted, maintained up-to-date and readily available. At all laundries bins used to transport uniforms, linens, blankets and personal laundry to and the divisions are cleaned and disinfected with Clorox disinfecting wipes before the cleaned laundry is placed in them.
Weekly, CCDOC tracks the amount of personal clothing sent to the laundry. The reports are provided at each Superintendent’s accountability meeting each week. The laundry supervisor
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records the amount by weight of laundry received from each division including linens, uniforms, and personal laundry.
CCDOC’s Inmate Information Handbook explains how laundry is handled and that the reasons detainees are not permitted to wash any clothing, towels and linens in the housing tiers. Additionally the Sanitarian developed and implemented the Laundry Detainee Worker Rules that establish accepted practices that must be followed.
CCDOC has issued a Divisional Orientation Handbook for the Laundry Unit. It is an orientation of the laundry procedures, assigned staff positions and responsibilities and procedures for fire safety, inmate count etc. After training laundry staff must take and successfully pas a written laundry orientation examination. There are written duties/responsibilities for laundry officers and supervisors for each shift.
Monitor’s Assessment:
The Monitor toured the laundries in Division 4 and 5. The Division 4 washer and dryers have been replaced and the ventilation modified to meet specifications. Both laundries were clean, and well organized. Inmate workers have specific assignments and were well supervised. Monitor’s Recommendations:
1. No further recommendations.
84. Sanitary Laundry Procedures
b. CCDOC shall ensure that inmates are provided adequate clean clothing, underclothing and bedding, consistent with generally accepted correctional standards, and that the laundry exchange schedule provides consistent distribution and pickup service to all housing areas
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC General Order 24.11.3.0 prohibits inmates from washing and drying uniforms, towels personal clothing or bed linens other than through the CCDOC’s laundries. It requires Living Unit Officers to confiscate clothing or linens being washed by inmates and issuance of clean, dry clothing and/or linen and issuance of an Inmate Disciplinary Report.
The policy and practice require uniform, and towel be exchanged twice each week, sheets once per week and blankets exchanged once per month. Personal clothing is collected twice per week from all housing units utilizing laundry loops to assure the detainee receives back what he/she sent. It is returned the same day and typically on the shift from which it was collected.
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A laundry schedule is posted in each living unit, and each division is required to include in its weekly Summary Report specifically which living units did not receive linen exchange as required by the policy. All laundry is washed using electronically dispensed detergent. White clothing also is washed with bleach. All clothing, linens and blankets are thoroughly dried at a high temperature The laundry maintains weekly logs that track daily of the amount of personal laundry cleaned from each division and have established benchmarking metrics based on weight of personal items and population data. The data is used to create trend reports by divisions that are shared with division superintendents and management. Weekly, CCDOC cleans between four and six thousand pounds of personal laundry in addition to uniforms, towels, sheets, and blankets.
Monitor’s Assessment:
During the tour CCDOC provided the laundry reports from June through November, 2016 along with the trending reports. The Monitor observed the posted laundry schedule in each housing unit of each division toured. The laundry operates three shifts daily to assure timely return of clean laundry. CCDOC has created posters explaining why all clothing needs to be cleaned and disinfected through the laundry, developed videos for the inmate televisions, and have taken designated inmates to visit the laundry to see firsthand the laundry process. Prior to this visit, the Laundry Commander noted that the amount of detainee personal laundry being sent for cleaning was decreasing in divisions 6 11 and the north tower of Division 9. . A laundry officer visited each of the tiers to meet with tier officers and detainees to take complaints and observe the laundry collection process. As a result inmate personal laundry in those divisions increased significantly. The provision remains substantially compliant.
Monitor’s Recommendations:
1. No further recommendations.
84. Sanitary Laundry Procedures
c. CCDOC shall train staff and educate inmates regarding laundry sanitation policies.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
Inmate laundry workers assigned to the laundry are trained as to their responsibilities by officers in accordance with General Order 24.11.3.0. The Order states the training includes both classroom and hands-on instruction as to the responsibilities, acceptable laundry sanitation practices and the use of laundry equipment, chemicals and the use personal
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protective equipment (PPE). Staff assigned to the laundry is required to successfully pass a written examination following the orientation training. Inmate workers are trained by staff supervisors and the laundry commander. Monitor’s Assessment: There is no change from the previous report. The Monitor toured the laundry in both Division 4 and 5. The laundry in Division 5 utilizes veterans serving time to work there. There is little turnover, but new inmates are trained as needed. This provision continues to be substantial compliance. Monitor’s Recommendations: 1. No further recommendations. 84. Sanitary Laundry Procedures
d. CCDOC 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. December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: Clean laundry is returned to the division from which it came in designated and marked “clean bins” that are sanitized with a disinfecting bleach wipe before clean uniforms, towels, bed linens and personal clothing are placed in the carts. All carts are thoroughly wiped by laundry workers and allowed to air dry. There are designated storage areas within each laundry that separate dirty laundry bins from those that have been cleaned and sanitized. Designated tables in each laundry are only used to sort and fold clean laundry. The tables are cleaned and disinfected at the beginning and at the end of each shift. Monitor’s Assessment: The Monitor observed the inmate workers folding clean clothing and linens. Staff adequately explained the process of cleaning and disinfecting laundry bins and tables. The provision continues to be substantially compliant.
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Monitor’s Recommendations:
1. No further recommendations.
84. Sanitary Laundry Procedures
e. CCDOC shall require inmates to provide all clothing and linens for laundering and prohibit inmates from washing and drying laundry outside the formal procedures.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
General Order 24.11.3.0 specifically prohibits inmates from washing and drying clothing, towels, or linen except through the designated CCDOC laundry. Living unit officers are required to confiscate any clothing or linen items being washed and replace them with clean dry clothing and/or linen. Inmate’s uniform, personal clothing, linens and blankets are collected in accordance with the schedule posted in each housing unit.
CCDOC provides laundry loops for inmate personal clothing and assists inmates in their correct use to help assure that their clothing will not get lost and can be adequately cleaned and dried. Personal laundry is returned to the inmate typically on the same shift of the same day it was collected. CCDOC has also removed laundry soap from the commissary order form to dissuade inmates from doing their own laundry. As discussed in 84.b, CCDOC continues to track by weight the amount of personal clothing submitted.
Monitor’s Assessment:
Use of the CCDOC laundry system for uniforms, towels, linens, and blankets is for the most part universally accepted and practiced. A review of the laundry trend reports demonstrates that the inmate culture to not use the laundry is clearly changing. CCDOC has posted easy to understand posters, schedules, and shown videos on televisions. Again on this tour the Monitor observed very little personal clothing drying in cells or dayrooms. However, on this tour the Monitor noted numerous ropes in Division 6 and 10 indicative of them being used to dry towels and more than likely personal clothing. Because this was only observed in isolated areas, the provision continues to be substantially compliant.
Monitor’s Recommendations:
1. Continue to regularly monitor and track the use of the laundry and as discussed above include a discussion and expectations as regular agenda topic at Divisional Superintendent’s accountability meetings.
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2. Supervisors need to enforce tier officers to collect ropes whenever they see them. The ropes can also be used as weapons against inmates and staff.
85. Food Service
a. CCDOC shall ensure that all food service at the Facility is operated in a safe and hygienic manner and that foods are served and maintained at safe temperatures.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CCDOC contracts the food service operation, currently CBM Premier Management to provide meals to all inmates. CBM utilizes the central kitchen for all food preparation. The Division 11 kitchen is only utilized to tray and then dispenses the hot meal for inmates housed there. Equipment and areas in both kitchens continues to be well maintained and clean.
CBM maintains responsibility for sanitation and maintenance of all equipment. They have two maintenance technicians who work on a schedule that allows for weekend coverage as needed. Area and equipment cleaning and sanitation are done by inmate workers who are trained and supervised by CBM employees. CCDOC officers assigned to the kitchen provide security.
Together CCDOC, and CBM have improved the process to assure that inmates receive the hot meals are received hot by significantly reducing the delivery time for transporting the food from the Central Kitchen to all divisions. CCDOC Sanitarians regularly monitor and record food temperatures at the time of delivery to compare it with recorded temperatures taken as the food is placed in trays in the kitchens. CCDOC Sanitarians, kitchen security officers and Support Services Superintendent meet weekly with CBM to review grievances and address both operational and logistic issues. A meeting summary is produced following each meeting. It includes a running list of outstanding issues including resolutions.
CBM regularly measures and records food temperatures as food is placed in trays and as it leaves the kitchen to the divisions. CCDOC Sanitarians conduct unannounced inspections of both food service kitchens to assure that meals prepared are safe and that kitchens operate in accordance with Illinois Food Code regulations. They also review the regulatory inspections of both kitchens completed by the City of Chicago Health Department and meet with CBM to assure any violations are corrected.
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Monitor’s Assessment:
CBM has and continues to work closely with CCDOC Support Services staff to identify and resolve issues related to food service. CBM and CCDOC staff conduct “town hall” meetings with groups of inmates to understand foods that inmates enjoy and foods they would like to see eliminated. It has resulted is several changes such as offering bagels and honey buns, breakfast bars, etc. As a result of the analysis of the transportation and food temperature study, the Monitor did not receive any complaints about hot meals not being warm or hot. Further CBM is well along in considering purchasing some new insulated carts small enough to fit into the elevators of Division 10 (currently the only Division where the existing carts are not able to be used because of size.) The Monitor continues to suggest that CBM regularly receive feedback from inmates to improved processes.
Food is no longer prepared at Division 11 kitchen. It is transported there in bulk and is put in the inmate service trays and distributed. All food is prepared at the Central Kitchen. This was done to shorten delivery time and assure hot meals are served hot to inmates.
CBM continues to provide cold meals on reusable trays or in sealed packaging that does not require a tray. On this visit, CCDOC is in the process of replacing both warewashers. As a result, during installation, Styrofoam trays will be used for all meals.
CBM has developed and implemented documented employee and inmate worker training programs, an internal inspection program, temperature monitoring program, formal staffing plans for employees and detainee workers, weekly cleaning schedules, a number of Standard Operating Procedures (SOPs), security standard and procedures, inmate kitchen worker orientation checklist, health screening, emergency evacuation plan in compliance with the fire safety committee, and an emergency food service contingency plan.
On this tour the Monitor the Central Kitchen, reviewed temperature logs, area housekeeping instructions, storage rooms, sanitizer concentration refrigerators, and freezers and observed the process of filling the trays. CBM effectively uses inmate workers to fill the trays and to clean under direct supervision of both CBM staff and CCDOC staff. The operation is efficient and well organized. The kitchen is maintained clean. CCDOC provided the most recent inspections of both kitchens by the local health department in September, 2016 with outstanding scores of 97 and 99% respectively. For the three total violations identified, CBM provided written evidence of that the corrections had been completed or work orders submitted. There were no critical violations identified. The violations included floor repairs in both kitchens and refrigerator wall needing repair in the central kitchen. This provision continues to be in substantial compliance.
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Monitor’s Recommendations: 1. No further recommendations. 85. Food Service
b. CCDOC shall ensure that all food service staff, including inmate staff, must be trained in food service operations, safe food handling procedures, and appropriate sanitation. December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: CBM management employees are Certified Food Safety Managers through the accredited ServSafe program and documentation is maintained showing that “Food Manager Certification” certificates that are current. CBM also provided copies of State of Illinois licenses for those that have completed a State recognized Food Training Program. CBM has established written job descriptions for all employee positions that include responsibilities and tasks. CBM provides orientation training to inmates daily. Inmates are required to sign an attendance sheet that is maintained by CBM management. A check list is used to assure inmates understand the food safety requirements pertaining to their assigned responsibilities. CCDOC Sanitarians developed an inmate training video that addresses health issues and personal hygiene that is shown to all potential inmate workers before they are assigned to work in the kitchens. Monitor’s Assessment: There is no change since the previous report. The State of Illinois requires food service managers to successfully complete a “State” approved food manager certification program. CCDOC provided certificates for three CBM management employees are currently certified by the State of Illinois. Eleven CBM employees have successfully completed the Serv-Safe Food Manager Certification. Certificates for those employees are posted in the employee break room. This provision remains in substantial compliance. Monitor’s Recommendations: 1. No further recommendations.
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85. Food Service
c. CCDOC shall ensure that the Central Kitchen and Division 11 kitchen are staffed with a sufficient number of appropriately supervised and trained personnel.
June, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE
Status Update:
CBM maintains a staff of 59 full or part time employees with schedules to assure adequate coverage for all meals daily and including weekdays. They have a written food service staffing guide that outlines the starting and ending times for all employees. The kitchen operates two shifts, as cold meals are prepared in advance of their serving, and maintained refrigerated as necessary. Additionally they utilize approximately 220 detainees scheduled over three, six or eight hour shifts just in the central kitchen to work in a variety of food service operations including preparation, filling meal trays, cleaning, warewashing, etc. Inmates from Division XI are assigned to work in that Division’s kitchen to prepare and tray the dinner hot meal. At both kitchens the contractor is responsible for providing training and supervision their employees and the inmate workers assigned to the kitchen. CCDOC staff only provides security services.
CCDOC provides inmate workers as needed. They also provide security officers for safety supervision of inmates and for tool control and staff to transport and serve meals to the divisions. CCDOC provides the security training of kitchen staff.
Monitor’s Assessment:
There is no change from the previous report. CBM provided a copy of its 2016 staffing guide for 59 full and part time positions. Support Services staff stated that CBM continues to maintain adequate number of qualified, trained and workforce at all times to assure timely preparation and service of meals to detainees. The regular weekly meetings between CCDOC Support Division including the staff sanitarians, security staff, CCDOC management and CBM leadership have been reduced to quarterly meetings and as needed because of the excellent relationship and the demonstrated cooperation of the contractor.
The provision remains in substantial compliance.
Monitor’s Recommendations:
1. No further recommendations.
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85. Food Service

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

December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE

Status Update:

Equipment, utensils, and food preparation areas including floors, walls, and facilities are maintained clean through shift and daily cleaning schedules established by CBM. They have created and posted written cleaning procedures for all equipment and areas in accordance with the equipment manufacturer’s specifications and a cleaning checklist/log for both kitchens along with a daily and weekly cleaning schedule for each room and the equipment in the kitchens such as the meat/packing room, wet room, bakery/packing room, dock, dry storage areas. It identifies what is to be cleaned, the frequency for cleaning and who is responsible for the cleaning. CBM trains, uses, and supervises inmate workers to clean and sanitize all areas identified on the cleaning schedule. Once completed, the supervisor initials the log and the records are maintained and are available for the Sanitarians to review during their inspections. The trays used for all meals are washed and sanitized after each meal and the cleaned trays are stored on appropriately designed racks that allow water to drain and the trays to dry between uses. CCDOC has two operating warewashers that are capable of cleaning and sanitizing equipment and utensils.

Monitor’s Assessment:

CBM continues to maintain all food service areas, equipment and utensils exceptionally clean. The kitchens are maintained as a model for institutional food service facilities. This includes walk-in refrigerators, freezers, dry storage areas, food preparation and assembly rooms, warewashing, carts used to transport food to the divisions, offices and laundry Both inmate workers and employees understand the expectation for cleanliness and disinfection of surfaces. Management and supervisors expect and demand excellence from employees and inmate workers. Inmate workers are quickly replaced when they do not perform.

CBM provided copies of cleaning procedures and cleaning schedules for the central kitchen, along with examples of cleaning logs documenting that assigned cleaning tasks were completed and approved by a supervisor. As reported earlier, CCDOC is installing two new Hobart flight type conveyor warewasher to replace the both Stero warewashers due to age and frequent repairs issues.

This provision remains in substantial compliance.

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Monitor’s Recommendations: 1. No further recommendations.
85. Food Service e. CCDOC 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.
December, 2016 COMPLIANCE STATUS: SUBSTANTIAL COMPLIANCE Status Update: There is no change from the previous report. The temperature monitoring and recording program implemented by CBM and monitored regularly by CCDOC Sanitarians demonstrates that this provision remains in substantial compliance. CBM has implemented an appropriate monitoring program to measure, record, and maintains logs for all refrigerators, freezers, and warewasher equipment. Logs of the temperature measurements are not only reviewed by CBM management, but also provided to the CCDOC Sanitarians weekly. Any required maintenance deemed necessary as a result of monitoring is completed by trained CBM maintenance workers. CCDOC Support Services Sanitarians, as well as regulatory inspectors continue to do independent monitoring of temperatures during their routine during unannounced inspections of both kitchens. Monitor’s Assessment: For this tour CBM provided example temperature logs for the vegetable refrigerator, breakfast cooler, dairy cooler, meat cooler, diet cooler, freezers, and warewasher wash and final rinse temperatures for both Stero machines. The Monitor again reviewed temperature logs onsite and those submitted at the tour. The monitoring logs were current, legible and reviewed by management This provision remains in substantial compliance. Monitor’s Recommendations: 1. No further recommendations.
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 Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 1 of 89 PageID #:5415

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

UNITED STATES OF AMERICA,

Plaintiff,

v.

COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),

No. 10 C 2946 Judge Virginia Kendall

Defendants,

Monitor Jeffrey L. Metzner, M.D.’s Report No. 14 May 2, 2017

Jeffrey L. Metzner, M.D., P.C. 3300 East First Avenue Suite 590 Denver, CO E-mail: Jeffrey.metzner@ucdenver.edu

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JEFFREY L. METZNER, M.D., P.C. 3300 EAST FIRST AVENUE SUITE590 DENVER, COLORADO
TELEPHONE (303) 355-6842 FACSIMILE (303) 322-2155 -

MEMORANDUM

TO:

Donald J. Pechous, Esq.

Cook County State's Attorney's Office

500 Richard J. Daley Center

Chicago, Illinois 60610

Paul O'Grady, Esq. Peterson Johnson& Murray 233 South Wacker, 84th Floor
Chicago, Illinois 60606

Kerry Dean, Esq. U.S. Department of Justice P.O. Box 66400 Washington, DC 20035-6400

FROM: DATE:
RE:

Jeffrey L. Metzner, M.D. May2, 2017 U.S.A_ v Cook County, et al No. 10C2946

I have completed my assessment of the mental health services offered at the Cook County Department ofCorrections (CCDOC) through Cermak Health Services ofCook County (CHSCC).
I site visited CCDOC from April 10-14, 2017.

Sources of information utilized in compiling this report included the following:
1. review of documents provided in response to my written request for pre-site information, which included the following documents: a. status update to the Agreed Order, b. numerous mental healthcare quality improvement studies, c. 21 healthcare records of mental health caseload inmates,
2. interviews with many inmates in group settings in Division 8 (RTU and the Cermak units) and Division 2 and Division 10,
3. observation of treatment activities in Division 8, 4. information obtained from key administrative and clinical staffthat included, but was not

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Re: Mental Health Services at CCDOC
USA v Cook County, et al.
Page2 of9
limited to, the following persons:
a. Jay Shannon, M.D. (CEO, Cook County Health and Hospitals System), b. Linda Follenweider, R.N., N.P. (Chief Operating Officer Hospital Based Services), c. Connie Mennella, M.D. (Chair, Department of Correctional Health Services), d. Nneka Jones Tapia, Psy.D. (First Assistant Executive Director), e. Kenya Key, Psy.D. (Chief of Psychology), f. David Kelner, M.D. (Chief of Psychiatry), g. Jane Gubser (CCDOC Chief of Programs),
As always, I found the staff from CHSCC and CCDOC to be courteous and helpful throughout my five-day site visit.
In this report the term "inmate" will be used in contrast to "detainee" in order to be consistent with the Agreed Order's terminology, although the vast majority of persons admitted to CCDOC are pre-trial detainees.
Overview
The Cook County Department of Corrections consists of 9 main divisions in a group of buildings covering over 100 acres. The inmate count during November 15,2016 was 8,029
Reference should be made to Appendix I for a more detailed summary of population and capacity information.
Findings
As per the June 3, 2010 memorandum regarding the June 2, 2010 meeting that included attorneys from the Department of Justice, attorneys and representatives ofthe Defendants, and the monitors, my findings relevant to the Mental Health Care section of the Agreed Order are summarized in Appendix IV (5-13-10 Agreed Order Mental Health provisions). Appendix IV includes excerpts from prior site assessment reports if they provide relevant contextual information. Consistent with the June 2, 2010 meeting, I have forwarded my input to the medical monitors who have primary responsibility for sections that overlap with various mental health provisions as summarized in the June 3, 2010 memorandum.
Appendix II summarizes the seventeen mental health provisions of the Agreed Order that have been in substantial compliance for at least 18 months, which includes one new provision being in this category. My assessment during this site visit did not raise any concerns that any of these provisions were no longer in substantial compliance. Appendix III summarizes mental health provisions of the Agreed Order monitored by other monitors.
Significant accomplishments since the November 2016 site assessment include substantial compliance being achieved with the following provisions:

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 3 of9
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures def"ming the various levels of care and identifying the space, staffmg, and programming that are appropriate to each identified level of care.
Substantial compliance with provision g is based on the assumption the 14.0 FTE mental health specialists' recently allocated positions will be filled in a timely manner and as well as the allocated psychiatrists' positions. The functional vacancy rate for the psychiatrists appears to be the lowest since the implementation of the Agreed Order. When allocated part-time and consulting psychiatrists' positions are translated in terms of FTEs, and psychiatric physician's assistant FTE positions are included, Cermak has approved funding for about 20 FTE line staff psychiatric provider positions in contrast to the 15.0 FTE line psychiatric positions described in the staffmg summary from 2014. It appears that 3.0.FTE psychiatrists will be hired by August 2017. Cermak has demonstrated a commitment to an ongoing staffmg needs assessment to ensure that the psychiatric staffing allocations will remain adequate. In addition, there is a filled 1.0 FTE Divisional Chief of Correctional Psychiatry position and a recently funded 1.0 FTE Associate Director of Correctional Psychiatry position that is being actively recruited.
The leadership of Kenya Key (ChiefPsychologist, Ph.D.), David Kelner, M.D. (ChiefPsychiatrist) and Carlos Gomez, Psy.D., Linda Follenweider, R.N., N.P (Chief Operating Officer Hospital Based Services), and Connie Mennella, M.D. remains very impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is very good. The leadership demonstrated by Director Nneka Jones, Psy.D. remains impressive.
Information Requests
Appendix V summarizes my revised document request for my next site assessment scheduled for the week ofNovember 13, 2017.The site visit will be three or four days in duration. At the present time I am planning to be on site from November 14-16.
Please do not hesitate to contact me if I can answer any further questions.
Sincerely,

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USA v Cook County, et a!. Page 4 of9
Jeffrey L. Metzner, M.D.

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Executive Summary-Fourteenth Monitoring Report (Mental Health Provisions)
Significant accomplishments since the November 2016 site assessment include substantial compliance being achieved with the following provisions:
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defming the various levels of care and identifying the space, staffing, and programming that are appropriate to each identified level of care.
Substantial compliance with provision g is based on the assumption the 14.0 FTE mental health specialists' recently allocated positions will be filled in a timely manner and as well as the allocated psychiatrists' positions. The functional vacancy rate for the psychiatrists appears to be the lowest since the implementation of the Agreed Order. When allocated part-time and consulting psychiatrists' positions are translated in terms ofFTEs, and psychiatric physician's assistant FTE positions are included, Cermak has approved funding for about 20 FTE line staff psychiatric provider positions in contrast to the 15.0 FTE line psychiatric positions described in the staffing sununary from 2014. It appears that 3.0 FTE psychiatrists will be hired by August 2017. Cermak has demonstrated a commitment to an ongoing staffing needs assessment to ensure that the psychiatric staffing allocations will remain adequate. In addition, there is a filled 1.0 FTE Divisional Chief of Correctional Psychiatry position and a recently funded 1.0 FTE Associate Director of Correctional Psychiatry position that is being actively recruited.
In addition, all provisions of the Agreed Order are now in substantial compliance except for provisions o and p due to timeframe issues related to the mental health services request form process, which should be remedied within the next month.
CCDOC has continued to implement a plan for increased out of cell time for all inmates in segregation units as part of the CCDOC plan to gradually increase the recreational time for segregation inmates to at least three hours per day. In addition, the custody staff is providing increased access to out of unit recreational areas throughout the compound as well as increased correctional rehabilitation programming to many mental health outpatient level of care caseload inmates.
The leadership of Kenya Key (ChiefPsychologist, Ph.D.), David Kelner, M.D. (ChiefPsychiatrist) and Carlos Gomez, Psy.D., Linda Follenweider, R.N., N.P (Chief Operating Officer Hospital

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Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 2 of8
Based Services), and Connie Mennella, M.D. remains very impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is very good. The leadership demonstrated by Director Nneka Jones, Psy.D. remains impressive.
An additional one provision has now been in compliance for at least 18 months, which means a total of 17 provisions have been in compliance for at least 18 months.
Four (4) provision previously in partial compliance are now in substantial compliance, which means there are now seven (7) provisions that have been in substantial compliance for less than 18 months.
Only one (1) provision remains in partial compliance, although this provision should be in substantial compliance within a very short period of time.
Summary of Compliance Findings
The following provisions were assessed to be in substantial compliance (with the initial date of substantial compliance noted in parenthesis):
Bolded provisions indicate that the provisions have been in substantial compliance for more than 18 months.
59. Assessment and Treatment
a. Results of mental health intake screenings (see proVIsion 45.c, "Intake Screening") will be reviewed by Qualified Mental Health Stafffor appropriate disposition. (6/12)
b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates' mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs. (10/12)
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staffwith appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental
2

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Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 3 of8

Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the imnate for appropriate treatment. Cermak shall request and review available information regarding any diagnosis made by the inmate's community or hospital treatment provider, and shall account for the imnate's psychiatric history as a part of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record. (11/16)

d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional. (4/17)
e. Cermak shall ensure that treatment plans adequately address inmates' serious mental health needs and that the plans contain interventions specifically tailored to the imnates' diagnoses. (4/17)

f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet imnates' serious mental health needs and ensure that psychiatrists see inmates in a timely manner. (11116)

g.

Cermak shall ensure timely provision of therapy, counseling, and other mental

health programs for all imnates with serious mental illness. This includes adequate

number of Qualified Mental Health Staff to provide treatment, and an adequate

array of structured therapeutic prograrmning. Cermak will develop and implement

policies and procedures defining the various levels of care and identifYing the

space, staffing, and prograrmning that are appropriate to each identified level of

care. (4117)

h. Imnates shall have access to appropriate infirmary psychiatric care when clinically appropriate. (11/16)

1.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with a mental health caseload roster listing the inmates

currently receiving mental health care. (6/12)

j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to

3

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Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 4 of8
minimize any deleterious effect of disciplinary measures on an inmate's mental health status. (1 0/12)
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
I. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staffwith appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. (11/15)
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year. (6/12)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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
4

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 10 of 89 PageID #:5424
Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 5 of8
for release. (4/16)
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record.
b. Cermak shall ensure timely implementation ofphysician orders for medication and laboratory tests. Cermak shall ensure that 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. (4/17)
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. 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. (11/13)
62. Suicide Precautions a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional
5

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 11 of 89 PageID #:5425
Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 6 of8

personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established
jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.
c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate
shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.
d. Cermak shall develop and implement policies and procedures for suicide
precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances. (11/15)

63.

Cermak shall ensure that Qualified Mental Health Staff assess and interact

with (not just observe) inmates on Suicide Precautions, and document the

assessment and interaction on a daily basis. (11/10)

64. Suicide Risk Assessments a. Cermak 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.

b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record. (11/13)

65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. (11/15)

66. Suicide Prevention Policies

6

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 12 of 89 PageID #:5426
Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 7 of8

a. CCDOC shall ensure that suicide prevention policies established jointly with
Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with
CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards. (6/12)

67.

DFM shall ensure that cells designated by CCDOC or Cermak for housing

suicidal inmates shall be retrofitted to render them suicide-resistant (e.g.,

elimination of protrusive shower heads, unshielded lighting or electrical

sockets). Inmates known to be suicidal shall not be housed in cells with

exposed bars. (6/12)

68. Suicide Prevention Training

a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics: (1) th~ suicide prevention policy as revised consistent with this Agreed Order; (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 wha are placed on Suicide Precautions; (8) case studies of recent suicides and serious suicide attempts (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools. (12/10)

70. Cermak shall document inmate suicide attempts at the Facility, as defined by the Suicide Prevention Committee's policies and procedure in accordance with generally accepted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.(6/12)

7

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 13 of 89 PageID #:5427 Executive Summary Eleventh Monitoring Report (Mental Health Provisions) Page 8 of8
86. Quality Management and Performance Measurement a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant. b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant. (11/15)
The complete list of provisions that were in partial compliance is as follows: 59. Assessment and Treatment
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
8

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 14 of 89 PageID #:5428 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 5 of9
Appendix I

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 15 of 89 PageID #:5429

Sheriffs Daily Report 4/10/2017

TOTAL MALE AND FEMALE Jail Population Community Corrections

Under the Custody of the Sheriff

Jail Population
TOTAL MALE AND FEMALE Division 2, Division 3 Annex, Division 6, Cermak, Division 08 RTU, Division 9, Division 10, Division II -Male Population Division 4, Cermak, Division 08 RTU- Female Population Division 15 - Outside Counties Division 15- Hospital
Court-Ordered Programming Within Jail Custody Division 16 - VRIC (Court Ordered) -Male Population Division 3 Annex, Division 2, Division 6, Division 08 RTU - PRC (Court Ordered Drug Treatment Program) -Male Population, Division 4 - Women 1s Residential (Court Ordered Drug Treatment Program)

Community Corrections Population TOTAL MALE AND FEMALE
Electronic Monitoring (Court Ordered) Men Women
M.O.M.s Program (Court Ordered) VRIC Post Release (Court Ordered)

9,811 7,620 2,191
7,620 6,794
481 103 26
22 141 53
2,191
1,930 245 0 16

4/10/2017

Page 1

DRAFTvl

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 16 of 89 PageID #:5430

Cook County Department of Corrections Executive Director's Log

Monday, April10, 2017

Prepared By: F. Khan

Totals:

7,620 100%

Male

7,086

93%

Female

534

7%

Div 1

Male
0

Female -

Total
0

Capacity
1,250

No Place To Stay
0

Div 2

1,758

- 1,758 1,960

64

Div 3

0

-

0

360

0

3 Annex

481

- 481

768

18

Cermak

120

17 137

148

6

Div4 Div 5

- 301 301

552

5

0

-

0

992

0

Div 6

904

- 904

992

12

Div 08

646 163 809

979

40

Div 9

812

-

812 1,066

0

Div 10

724

- 724

768

7

Div 11

1,490

- 1,490 1,536

4

Div 17 W. Residential

-

53

53

152

0

Div 15- HP

26

-

26

-

2

VRIC In Camp

22

-

22

-

0

Outlying Counties Totals:

103

-

103

-

0

I 7,086! 5341 7,6201 11,5231 158

4/10/2017

Page2

DRAFTv1

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 17 of 89 PageID #:5431

Sheriffs Daily Report 4110/2017

TOTAL MALE AND FEMALE Jail Population

Under the Custody of the Sheriff

9,811 7,620 2,191

Jail Population
Behind the Walls

f11 Division 2~ Division 3 Annex, Division 6,
Cermak, Division OS RTU, Division 9, Division 10, Division 11- Male Population • Division 4, Cermak, Division 08 RTU Female Population
• Division 15- Outside Counties
• Division 15- Hospital
Court-Ordered Programming within Jail Custody
• Division 4- Women's Residential {Court Ordered Drug Treatment Program}
D Division 3 Annex, Division 2, Division 6,
Division 08 RTU - PRC (Court Ordered Drug Treatment Program) -Male Population
• Division 16- VRIC (Court Ordered} -Male
Population
Q. What does Behind the Walls mean? · A. The behind the walls jail population is physically housed under the Sheriff's
custody 24 hours a day/7 days a week. This includes all the populations listed on the key above and pie chart to the left- Divisional populations male & female; Outside Counties, Hospital, PRC, Women's Residential, & VRIC. Detainees in court-ordered treatment programs (PRC, Women's Residential, VRIC) are housed at CCDOC 24 hours a day/7 days week.

4/10/2017

Page3

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Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 18 of 89 PageID #:5432
Re: Mental Health Services at CCDOC USA v Cook County, et a!. Page 6 of9
Appendix II

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 19 of 89 PageID #:5433

59. Assessment and Treatment

a. Results of mental health intake screenings (see proVIsiOn 45.c, "Intake Screening") will be reviewed by Qualified Mental Health Staff for appropriate disposition.

Compliance Assessment: Substantial compliance (since June 2012).

b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates' mental health needs. Said policies shall include defmitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs.

Assessment: Substantial compliance (since October 2012)

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with a mental health caseload roster listing the inmates

currently receiving mental health care.

Assessment: Substantial compliance (since June 2012)

j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status.

Assessment: Substantial compliance continues (since October 2012).

k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.

I. Cermak shall ensure that mentally ill inmates in segregation receive timely and appropriate treatment, including completion and documentation of regular rounds in the segregation nnits at least once per week by adequately trained Qualified Mental Health Professionals or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional to

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 20 of 89 PageID #:5434
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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Substantial compliance (11115)
m. Cermak shall maintain an updated log ofinmates receiving mental health services, which shall include both those inmates who receive counseling and those who receive medication. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year.
Compliance Assessment: Substantial compliance (since June 2012)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation ofan inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation ofan inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
Compliance Assessment: Substantial compliance (since 4116)
61. Suicide Prevention Policy a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 21 of 89 PageID #:5435
c. 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.
Compliance Assessment: Substantial compliance (11/13)
62. Suicide Precautions
a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their mouitoring and checks.
c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.
d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
Compliance Assessment: Substantial compliance (11/15)
63. Cermak shall ensure that Qualified Mental Health Staff assess and interact with (not just observe) inmates on Suicide Precautions, and document the assessment and interaction on a daily basis.
Compliance Assessment: Substantial compliance (since November 2010)
64. Suicide Risk Assessments

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 22 of 89 PageID #:5436
a. Cermak 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.
b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level oflethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate's medical record. (11/13)
65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11115)
66. Suicide Prevention Policies
a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
Compliance Assessment: Substantial compliance (since June 2012)
67. DFM shall ensure that cells designated by CCDOC or Cermak for housing suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars.
Compliance Assessment: Substantial compliance (since June 2012)
68. Suicide Prevention Training

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 23 of 89 PageID #:5437
a. Cermak shall ensure that the Facility's suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (2) why facility environments may contribute to suicidal behavior; (3) potential predisposing factors to suicide; (4) high risk suicide periods; (5) warning sigus 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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools.
Compliance Assessment: Substantial compliance (since December 2010)
70. Cermak shall document inmate suicide attempts at the Facility, as def"med by the Suicide Prevention Committee's policies and procedure in accordance with generally accepted correctional standards, in the inmate's correctional record in CCDOC's new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.
Compliance Assessment: Substantial compliance (since June 2012)
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 24 of 89 PageID #:5438
resolution, for each of the provisions of this Agreed Order applicable to that Defendant. Compliance Assessment: Substantial compliance (11115)

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 25 of 89 PageID #:5439 Re: Mental Health Services at CCDOC
USA v Cook County, et a!.
Page 7 of9
Appendix ill

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 26 of 89 PageID #:5440
Appendix III
Mental health provisions of the Agreed Order monitored by other monitors
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
Compliance Assessment: Refer to the report by Dr. Shansky (initially found to be in substantial compliance during 2011 and again during 2013)
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily available, safely secured, suicide cut-down tools.
Compliance Assessment: Refer to the report by Susan McCampbell.

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 27 of 89 PageID #:5441 Re: Mental Health Services at CCDOC
USA v Cook County, et al. Page 8 of9
Appendix IV

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 28 of 89 PageID #:5442

Appendix IV The Agreed Order Status Update Page 1 of 59

P: AGREED ORDER

D. MENTAL HEALTH CARE

59. Assessment and Treatment

c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-N-TR. or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, lmds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate's medical record.

Compliance Assessment: Substantial Compliance (11116)

Factual Findings:

Apri12017 Cermak Status Update

April2017

Total Jail Population as of3/23/2017: 7,598

P2-0utpatient Mental Health

1679 22 % (of total)

P3-IntermediateMental Health 394 5.1% (oftotal)

P4-Psych. Special Care Units

74 0.97% (of total)

Mental Case Caseload

2,147 (29%)

78% (ofMH load) 18.35% (ofMH load) 3.4% (ofMH load)

October 2016

Total Jail Population as of 10113/2016: 8,226

P2-0utpatient Mental Health

1711 20.7% (of total)

P3-Intermediate Mental Health 436 5.3% (of total)

P4-Psych. Special Care Units

86 1.05% (of total)

76.62%9(ofMH load) 19.5% (ofMH load) 3.85% (ofMH load)

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 29 of 89 PageID #:5443

AppendixN The Agreed Order Status Update Page 2 of 59

Mental Case Caseload

2,233 (27.14%)

The number of patients on Mental Health Caseload has remained relatively stable. Fnrthermore, the proportion of detainees in Intermediate Level of Care and Outpatient Level of Care- P3 and P2, respectively, has remained constant. Various diversion programs have not diminished the proportion of the seriously mentally ill and the violent offenders.

; ,:.:··· ~~f"i4,¥~
Jail Populatiot;t,":r:"}
Behind the Walls:'.!'%·
!B Division 2, Division 3 Anr~ex, Division 6,
Cermak, Division 08 RTU, Division 9, DivlsionlO, Division 11 ~Male Population
fB Division 4, Cermak, Division 08 RTU -
Female Population
11 Division 15- Outside Counties
• Division 15 - Hospital
Court-Ordered Programming
within Jail Custody
Rl Division 4- Women's Residential {Court
Ordered Drug Treatment Program)
D Division 3 Annex, Division 2, Division 6,
Division 08. RTU- PRC {Court Ordered Drug Treatment Program)- Ma!e Population
11 Division 16- VRlC (Court Ordered)- Male
Population

All Providers, Psychologists, MSW and MHS continue to use their personalized access to the Jail Data Link database allowing them to source data about previous admissions to municipal and state institutions receiving federal grants or directly administered by the State of IL All Providers, Psychologists, MSW and MHS have personalized access to the Jail Management System (CCOMS) allowing them to review charges, legal and disciplinary history in real time. All the WYSE terminals and desktops that Cermak utilizes across the compound (including RCDC) permit CCOMS access.
Mental health staff are routinely seeking releases of information for community providers during the intake process and post intake when needed. Dr. Gomez remains a lead coordinator for this task. Relevant data was obtained and is available as a separate CQI study in the PDF Appendix to this Status Update Report.
On average more than 47% of female detainees and approximately 24% of male detainees are

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 30 of 89 PageID #:5444
Appendix IV The Agreed Order Status Update Page 3 of 59

referred for secondary mental health assessment from the initial health screening. Additionally, appropriate identification ofmental illness and placement on the mental health caseload at intake remains consistently over 90%. Please see Excel Appendix for Jntake Referral data.

Dr. Gomez continues acting as the clinical supervisor in the RCDC area. Dr. Butler is in her second week of orientation to replace Dr. Gomez as RCDC Unit Director. During RCDC group supervisions case conferences, including peer review, are conducted to address the quality of secondary mental health assessments and identify outliers among staff. The main focus is to discuss quality of dispositions and risk assessments. Dr. Gomez conducted an ongoing audit and analysis of assessments and dispositions made by the Jntake QMHP staff, find excerpts below. The full RCDC QI (MH Disposition at Jntake) report can be found in the PDF Appendix.

The double blind audit of 42 intake mental health assessments reflected a high level of concurrence between the supervisor and individual assessors' dispositions. There was also a high level ofinterrater variability.

Psychiatry Face to Face visits:

October 2275

November I December I January I February I

2095

11893

112291

112070

I

Physician Assistant Face to Face visits:

October 235

November December January

257

199

230

February 471

Physician Assistants continue to exceed productivity quotas and, overall, their performance is very good. Based on prior discussions, new PA who joined Cermak early in January was assigned primarily to P2 areas (Division IV).

Dr. Kelner reviewed psychiatry referrals originating in the intake process as per below (also see Excel Appendix for data):

Psychiatry Jntake Referrals:

Order Priority Status
Month

Seen

#

%

Emergency

Not Seen

I I# 2) Over 4hrs

4)NoNote

#II % II# I % I

%

Total

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Appendix IV The Agreed Order Status Update Page 4 of 59

2017 02 12911
2017 01 1191
1201712 ~
12017 11 156
I l2o11 10 16611

94.85% lwl
97.54% wl 98.15% wl 96.30% wl 97.65% 1411

2.94% lwl
1.64% lwl
1.85% 1n1
1.85% IWI
2.35%101

2.21% IWI
0.82% lwl
IW
1.85% 1w
1w

I 5.15% 1361 I 2.46% 122
1.85% 108 3.70% 162 2.35% 170

In February 2017 94.85% detainees were seen within 4 hours (in keeping with the timeframe) when referred with Psychiatry Emergent Referral. Out of the 5.15% that were not seen timely, 2.94% were still seen in RCDC (Intake) but outside ofthe 4 hour timeframe. 2.21% were not seen in Intake, as they were either fast tracked, given acuity, prior to Psychiatrists being able to see them, to PSCU and MSCU/detoxification uuits. Additionally, and in keeping with prior data, a small proportion of that cohort had orders for Psychiatry Intake placed in EMR when it was assumed by MHS that Psychiatry would be present on site, but then, due to call offs Psychiatrists did not show up and original orders were not cancelled. Ofnote is that, even when MH cancel those Psychiatry Emergent Referrals orders, Cerner still captures them subsequently. A work order has been created to address the fix in EMR.

II Urgent(P4) II

1) Within 24 hrs

II

2) Over 24 hrs

No Note

Total

12 2017

I 79

96.%

I2

2.%

I

1.%

82

1~ 2011

I 68

93.%

I2

3.%

3

4.%

73

112 2016

I 58

95.%

I2

3.%

I

2.%

61

In 2016

I 75

89.%

I7

8.%

I 2

2.%

84

Ito 2016 I 87

96.% IG:JI

4.%

I

91

In February 2017 96% of detainees referred for Urgent Psychiatry Referral were seen within 24 hours (in keeping with the tirneframe). The 2% of detainees that were not seen within the next 24 hours were mostly detainees that fell into one of the following categories: a. Admitted on Fridays and weekends. Psychiatrists saw them later in the day and detainees who were assigned P4 level (were "slated" for PSCU admission) and then were diverted to MSCU and detoxification Units, thus delaying their contact with Psychiatry. Daily PSCU Mental Health Level of Care Tracker continues to allow Psychiatric Providers review lists of patients with P-alerts in MSCU and see when notes are due. b. Transferred to John Stroger Hospital due to medical problems and detox and could not be seen within 24 hours by Cermak Psychiatrists. An internal system of notifications between JSH Consultation and Liaison Psychiatrists and Cermak Providers serves to alert JSH CIL Service to CCDOC detainees' arrival.

Routine(P2/P3)
2 2017

1) Within 14

days

ll318

82.%

2) Over 14 days
30 II 8.%

5) D/C over 15 days without
Note

I 6) No Note

13 II 3.% I 25 II 6.%

IB
386
I

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AppendixN The Agreed Order Status Update Page 5 of 59

1 2017 12 2016 11 2016 10 2016

303 79.% 34

9.%

24

6.%

24

0 6.%

257 74.% 41

12.%

26

7.%

25

7.%

349

G J W 331 78.%

38

9.%

18

4.%

425

CJ~GJWCJ 4.% 8 2.%

439

In February 2017 318 (82%) detainees referred for Routine Psychiatry referral were seen within 14 days (in keeping with the timeframe). 30 (8%) were seen by Psychiatry outside of the timeframe (but under 22 days mark). Chart audit for the cases that did not have Providers' notes in EMR in February and January 2017 revealed that, when all the false positives and discharges from custody are subtracted, the actual number of detainees not seen as Routine Psychiatry Referrals was much smaller. Thus, out of 38 patients who were captured by Cemer as not having notes, only 10 did not truly have a note in February (No Note and Scheduling Issues in the corresponding chart above) and out of 48 patients in January- only 9. The resultant calculation is 88% of patients in February and 80% patients in January had notes written within appropriate timeframes.

Two major recurring trends have been identified as a result of 87 chart audit/review:

• Cerner continues to capture many IDOC transfers (most of them were parole holds upon admission to CCDOC)/Electronic Monitoring releases/Furloughs/15SFFP/, and extraditions as being physically on campus and, therefore, they are seen as "never having contacts with Psychiatry''.
• Scheduling and scheduling related errors remain an area of vulnerability. Cermak MH Leadership address scheduling issues with the Scheduling Supervisors. COO took over the scheduling Department and a new system of training and oversight is being introduced.

Daily reports for P Level detainees returning on the compound after hospital stays (15HP) are automatically generated, translated into an automated report, and become available to staff.

Outlying County returns reenter the compound after undergoing a Medical Mini screening as well as MH evaluation in RCDC. Their appointments with Psychiatry are rescheduled by a MHS. Medications are restarted once their housing is determined.

To further improve detainees' access to care and assure that Providers have enough time allotted to assess patients face to face and review medical records, a new Pilot scheduling program has been designed and being implemented in Division VI. The start date is April 1'1• The new scheduling template will allow schedulers to schedule detainees for 40 minutes for their Initial Psychiatric evaluations and 20-30 minutes for subsequent follow up appointments, before the practice is expanded to the rest of Psychiatry Clinics on the compound.

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Appendix IV The Agreed Order Status Update Page 6 of 59
In November 2016, the DOC formalized the process designed to facilitate after booking referrals from DOC to Cermak through the CCOMS/EMR interface by creating an alert for a "DOC Intake Mental Health Referral" for all detainees with certain charges compiled conjointly by CermakJDOC. The alert is entered by DOC RCDC staff and is communicated to Cerner via electronic medical record. Due to expressed concerns regarding the interface and the possibility ofthe alert not transferring to Cemer, DOC continues to notify Cermak mental health staff of such referrals verbally and through use ofthe alert until the interface issues are resolved. Since November 95 DOC Intake MH Alerts have been assigned. 38 charts were audited (all March and February 2017); dispositions: GP- 19 (50%); P2-7 (18%); P3-5(13%); P4-7(18%). Since most ofthe alerts were assigned to males, dispositions for males elsewhere collected (Initial caseload February 2017-males, following MH Intake) were used as controls to compare · the sensitivity of the existing alert:
Initial Case load Admitted on the Month of 02_2017 (include Discharge and non-active order status) Male Mental Health Classification within 3 day after Admit P2- Outpatient Mental Health 300 62.89% P3- Intermediate Mental Health 86 18.03% P4- Infirmary Mental Health 58 12.16%
The false positives (detainees referred to MH and dispositioned to General Population by Mental Health staff eventually) constituted 50% ofthe audited population. On the other hand, the combined rate of admissions to P3 and P4 (SMI) made up 31% which approximates the 30% rate ofreferrals to those Levels of Mental Health Classification obtained byMH staff.
April2017 Metzner assessment: Substantial compliance continues. The percentage of the total population on the mental health caseload as well as the percentages specific to the various levels ofmental health care being used are consistent with national averages. The quality improvement studies relevant to the mental health screening process continues to be a very useful supervisory/peer review process as do the other audits relevant to this provision. Compliance with urgent and emergent psychiatric referral timelines continues to be maintained as does compliance with obtaining release of information consent forms when clinically appropriate.
Recommendations: Continue to monitor.
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Substantial compliance (4/17)
April2017 Cermak Status Update

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Appendix IV The Agreed Order Status Update Page 7 of 59
COMPOUND HOUSING PLAN BY MENTAL HEALTH LEVELS OF CARE (as of April 2017)
Cermak- P4 (Psychiatric Special Care Unit)- 2N acute male, 2W-acute aod chronic female, 2S/2SE- male subacute, 2E- male chronic, P4 cao also be housed on the third floor in Medical Special Care Unit under special circumstaoces. Housing on 3S for Mental Health reasons requires transfer orders from PCC/ Dr. Mennella. Patients with M4 aod P4 cao be housed on the Medical Special Care unit based on interdisciplinary decision.
• Division II: MALE MENTAL HEALTH HOUSING • Dorm 2: Mental Health Outpatient P2; **if aoy Mental Health Intermediates (P3) are placed there, MH staff works on traosferring them to RTU; CCDOC houses detainees that attend MHTC (Mental Health Traosition Center) in Division II Dorm 2 • Dorm 1: NO MENTAL HEALTH HOUSING • Dorm 3: NO MENTAL HEALTH HOUSING • Dorm 4: NO MENTAL HEALTH HOUSING
• Division IV FEMALE MENTAL HEALTH HOUSING o (Women's Justice- SWJP): FEMALE MENTAL HEALTH HOUSING-1st Floor • Mental Health Intermediates P3 (requires clearaoce from DWJS staff) • Mental Health Outpatients P2 (requires clearaoce from DWJS staff) o Mental Health Outpatient P2- 2nd floor o M2- Protective Custody
• Division V: NO MENTAL HEALTH HOUSING • Division VI: MALE MENTAL HEALTH HOUSING
o Westcare tier -2B (substaoce abuse, court ordered treatment program), Mental Health Outpatient P2
o SMU-2D o Protective Custody: 1A, 1B aod 1C
• Mental Health Outpatient P2 (only require mental health clearaoce prior to placement/ within 24 h ifrestricted housing rules apply) **No Mental Health Intermediates P3 should be cleared by mental health to traosfer to PC in Division VI; they should only be cleared for PC in Division VIII RTU
• Division VIII RTU: MENTAL HEALTH HOUSING o 5th floor Females • Mental Health Intermediates P3 (tiers B, F) Mental Health Outpatients P2 aod DETOX (all other tiers), Pre/postnatal • SMU (tier A) Protective Custody (tier E) (restrictive housing require mental health clearance prior to placement/within 24 h) o 4th floor Males • Mental Health Intermediates P3 (all tiers) SMU (tier A) Protective Custody (tier E)

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Appendix IV The Agreed Order Status Update Page 8 of 59
• Mental Health Intermediates P3 (restrictive housing require mental health clearance prior to placement/within 24 h)
o 3'd floor Males • Medical Intermediate M3s (may also be P2s) with overflow Mental Health Intermediate P3s
o 2nd floor Males • Mental Health Intermediate Overflow P3 • Intensive Management Unit (tier 2A)-P3 • DETOX
• Division IX: MALE MENTAL HEALTH HOUSING o Protective Custody (Tiers 3G, 3H) • If conditions of confinement are more restrictive than GP, Mental Health Outpatient P2 require mental health clearance prior to placement/within 24h **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division IX; they should only be cleared for SMU in Division VIII RTU o SMU- non-administrative SMU (Tier IE, IG, IH; IF- enhanced security tier) • Mental Health Outpatient P2 (require mental health clearance prior to placement/within 24h) **No Mental Health Intermediates P3 should be cleared by mental health to transter to SMU in Division IX; they should only be cleared for SMU in Division VIII- RTU o General Population (all other tiers in the division) • Mental Health Outpatient P2
• Division X: MALE MENTAL HEALTH HOUSING: Mental Health Outpatient P2 **if any Mental Health Intermediates (P3) are placed there, MH staff works on transferring them to RTU o Protective Custody -I C (meeting criteria of SMU housing) and 2C • **No Mental Health Intermediates should be cleared by mental health to transfer to SMU/PC in Division X; they should only be cleared for SMU in Division VIII RTU o 2B- Therapeutic Tier (non P3)
• Division XI: NO MENTAL HEALTH HOUSING • Division XVI (Boot Camp): NO MENTAL HEALTH HOUSING; detainees on dose by
dose medications cannot be in Boot Camp (and that excludes any patient on psychotropics)
Compound Housing Discussions:
Residential Treatment Unit Average daily Population is 400 P3's and I90 P2's. Average SMU/IMU population 23. Of note, that there are no P3 patients housed outside ofRTU and the need to create more P3 tiers to accommodate P3 overflow previously housed in Division X has significantly diminished.

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Appendix IV The Agreed Order Status Update Page 9 of 59
Updates: RTU Male Services
RTU males are housed on the second, third and fourth floor of the RTU building. Psychiatric services in Male RTU have been expanded. Staffing levels in this high priority area (RTU) remain a focus for Psychiatry Administration. Additional psychiatric allocations were made following a series of discussions. Psychiatry Clinics were opened on the second floor ofRTU. They were originally designed to differentially serve the needs of detainees housed on the 3'd and 2"d floor ofRTU. At present, schedulers try to schedule detainees from the 2"d and 3n1 floors to the second floor clinics. Present Psychiatric allocations in RTU are outlined in the staffing section of this Status Update report, see 59f.) Psychiatric allocations absorb Special Management Units with average daily census 18 (mixed Classification Units within the building housing detainees with various combinations ofP3,P2, and M- Alerts)+ Intensive Management Unit with average daily census 6 (housing detainees with P3 Level of Care). A designated Provider exists to provide psychiatric care for SMU/IMU populations and participate in the Multidisciplinary Treatment meetings on IMU. Dr. Sillitti is the Unit Director and coordinates all male services in RTU.
Since October of2016, RTU Male Services has continued to focus upon increasing group programming hours for P3 detainees, expanding services to the protective custody tier, maintaining compliance with treatment plan timelines for intermediate care, addressing P3 overflow, and coordinating with CCDOC to minimize group cancellations. The following overview provides a summary of these efforts.
Prior to the staff rotation in December of 2016, RTU male services was short three staff, which significantly impacted programming hours for six intermediate care dorms, three special housing units (PC, SMU, IMU), and two overflow units. With the rotation and hiring of new staff, RTU male services currently has nine MHS III staff and three MHS II staff. One position remains vacant due to the illness and extended recovery of one MHS. Based upon current staffing and required programming for the ten aforementioned tiers, RTU inmates have an average participation of approximately 8 hours of programming for P3 dorms, 7 hours of programming for specialty units (SMU and Protective Custody), and 10 hours of group sessions for the IMU tier. As outlined in previous summaries, detainees attend the following core groups by bed number: Emotional Management, Interpersonal Skills, and Problem Solving. These sessions review relevant skills for all detainees in intermediate care. Voluntary groups are also offered to address the individual needs of patients. MH staffmeet individually with detainees for orientation upon their admission to RTU to discuss the treatment program, review behavioral expectations, and identifY treatment goals. At that time, detainees rank order their preferences for voluntary groups and are included in those sessions. Verification letters continue to serve as an incentive for participants who attend at least 75% of their groups. Consistent with previous estimates, approximately 17-30% of detainees on dorms earn letters for their participation.
Planned and unplanned staff absences remain the predominant reason for group cancellations. The most newly hired staff in RTU has been assigned to make up groups whenever possible,

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Appendix IV The Agreed Order Status Update Page 10 of 59
which has been helpfuL Scheduled progrannning hours will continue to increase for intennediate care with the addition of mental health specialists, particularly when the IMU program gains a separate and dedicated staff.
Programming on the Protective Custody tier (4E) has been well received by detainees. MH staff generally provide on tier sessions, but have conducted off tier groups when space is available and CCDOC approves movement. Initially, medium and maximum detainees were being seen more frequently due to the timing of the groups and "hours out" for those classifications. After realizing this disparity, MH staff have put forth increased effort to coordinate with tier officers and provide equal opportunity for minimum status detainees. Apart from staff absences, the most frequent barrier to progrannning on this tier has been staff attention to other clinical duties including mental health clinic, interagency evaluations, crisis intervention, and health service request forms. Again, programming on 4E will increase as mental health staff are added to the team.
The Special Management Unit (SMU) has posed the greatest challenge for group progrannning. Whereas Division 8 previously allotted two tiers (3A and 4A) for disciplinary housing, all males in RTU currently serve disciplinary time on 4A. Consequently, detainees who are general population and/or P2 level of care complete disciplinary time on the same unit with detainees in intennediate care. Over the past few months, several detainees who are well known for behavioral problems in Division 9 and 10 were housed in RTU for medical attention. They were placed on 4A due to their lengthy sanctions, which often exceeded one hundred days. Those detainees repeatedly engaged in maladaptive behavior on the tier including verbal and physical aggression, staff assault, flooding, smearing feces, and throwing liquids in the day room. Groups were repeatedly cancelled as a result of these unsafe behaviors, as tier officers needed to respond to the situations or lock down the unit. In addition, the general population and higher functioning detainees actively sought to interfere with group sessions in attempt to keep the day room open for "hours out" and television use. To illustrate, multiple P3 detainees admitted they refused group after they were either ''bribed" or threatened. Other institutional factors contributing to group cancellations on this tier included a lack of handcuffs, conflicts with "hours out," and medication pass. These issues were discussed in interagency meetings, where potential solutions were considered. Alternative spaces for group sessions were explored, including the bullpen and patio when other rooms are in use. CCDOC recommended the installation of rings to the bullpen in order for the space to become a viable option for group sessions. MH staff continue to collaborate with nursing and tier officers to avoid scheduling conflicts.
In terms of treatment plans, each dorm has an assigned MHS III who conducts a core group for the tier and develops a 30 day treatment plan based upon the detainees' mental health diagnosis and self-report during the initial orientation session. The mental health team then aims to review the treatment plan within 90 days to discuss patient progress, clinical concerns, and recommendations for level of care. Weekly multidisciplinary (MDT) meetings are held on both day and evening shifts to facilitate team collaboration on treatment plans. Oftentimes, the number of people reviewed during the MDT does not allow time for direct contact with detainees

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Appendix IV The Agreed Order Status Update Page 11 of 59
discussed. The clinical team on the evening shift therefore added group supervision sessions to meet with patients, discuss clinical goals, and offer feedback. According to MH staff, this time has been especially useful to reinforce concepts discussed in groups and to address clinical issues with detainees as a team.
All MHS III's were encouraged to create a database for their tiers in order to track the timeliness of 30 and 90 day treatment plans. Some MH staffhave excelled at this task; others have struggled to maintain their excel sheets, which occasionally results in delay of MDT discussion and treatment plan review. Despite these challenges, compliance with both 30 day and 90 day P3 treatment plans has improved. The MH team will continue to streamline this process to effectively track and complete treatment plans within specified time frames.
Treatment plan review during weekly MDT meetings serves as the primary method by which the team monitors the P3 population in attempt to reduce overflow on other floors. Each week, MH staff place names on the MDT list for review due to an upcoming treatment plan revision or due to the patient's clinical presentation during treatment sessions. All detainees in SMU, PC, and overflow units are reviewed briefly to alert the team of clinical concerns. In addition, the team typically identifies an average of 9 to 10 individuals who are stable for outpatient care each week. MH staff observe many detainees to be highly motivated to remain in the dorm setting. Currently, CCDOC does not have dorm housing for P2/Maximum detainees. As a result, a portion of detainees often attempt to obtain preferential housing in RTU by exaggerating symptoms, requesting mental health treatment, and /or engaging in problematic behaviors. In January, Cermak administration proposed a therapeutic tier in Division 10 to provide additional support and monitoring for P2/Maximum and Medium detainees. The tier was approved to be started in mid-March. Ideally, the addition of this tier will help to increase mental health services for higher functioning detainees while decreasing the number of patients who intentionally return to intermediate care. While the motivation for readmission to a higher level of care than necessary remains present for some patients, the clinical staff do a great job of maintaining patients at the appropriate clinical level of care. Please refer to QI titled Readmission to P3 in the Appendix.
Since the last DOJ visit, the CCDOC and mental health teams have collaborated closely to address the most significant obstacles to group programming. A new joint schedule was developed to account for group programming as well as recreation. Following implementation ofthis schedule, cancellations due to recreation have decreased markedly on RTU 4th floor. Moreover, the lack of movement officers during the 3 to 11 shift previously resulted in repeated group cancellations. Over the past two months, CCDOC leadership approved for tier officers to assist with group observations, which has also reduced security related cancellations on the second shift. In terms of other endeavors, CCDOC and mental health staff have attempt to lead joint community meetings as often as possible (approximately once a month to once every two months) to address detainee concerns. Per MH staff, detainees have expressed appreciation for these meetings and the immediate actions that often follow.

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AppendixN The Agreed Order Status Update Page 12 of 59
Updates: Intensive Management Unit
The Intensive Management Unit (IMU) is located on the second floor or RTU. Dr. Kaniuk is the Unit's Director. The Psychiatrist assigned to SMU/IMU in RTU is Dr. Paschos. This specialized 10 bed capacity program is designed to provide increased structure and support for mentally ill detainees who have demonstrated significant problems in their functioning. The program consists of three successive phases (Assessment and Admission Phase-minimum 2 weeks; Stage 1- minimum 4 weeks; and Stage 2-minimum 4 weeks) which offer increased incentives as the detainee progresses. Recently the 3'd Phase (Residential) was introduced to accommodate program graduates who have lower functioning/significant deficits and expected to do poorly in the dormitories in RTU. All of the detainees selected for the program thus far incurred notable segregation time due to severe behavioral problems (e.g. assault against others; property damage; sexual misconduct; threats and noncompliance; coprophagia; insertion of foreign objects; ingestion of foreign objects; using ligatures for self-harm). These detainees were informed that their participation and successful completion ofthe program could result in absolution of segregation time for previous disciplinary tickets. Disciplinary Board approaches infractions incurred during detainees stay in IMU with deference to MH input. Additionally, a Letter of Completion is signed by the Superintendent and The Unit Director and is to be shared with Criminal Court Judges as a mitigating factor in the presentencing considerations.
The program continues to provide more than 10 weekly hours of structured out of cell therapeutic programming. Currently, two groups are held Monday through Thursday mornings. One group is performed on Friday morning. There is an evening group conducted Tuesday through Friday. One new staff member has been added to provide more hours of group programming. Group content includes, but is not limited to positive psychology, anger management, substance abuse, domestic violence, communication, coping skills, and DBT. The CRW comes to the tier on a daily basis. There is a weekly on-tier staffing where each detainee receives feedback regarding medication compliance, group attendance, and behavior in the program. A weekly staff meeting is held to discuss how each detainee is doing and to decide their status in the program. The medical social worker in the building addresses family issues, discharge medications, and provides linkage services to community agencies.
The IMU team meets for weekly MDT meetings and holds on tier meetings with the detainees every week to review treatment progress and expectations. The collaboration and communication amongst this disciplinary team has been essential to facilitate the progress of detainees. A joint training of new staff(manualized approach along the lines of trauma informed care) is planned since the original staffwho began working in IMU in 2015 has been displaced. Currently, the team continues to work on maintaining consistency across shifts (especially 2nd and 3rd shifts) and personnel. Security personnel who are assigned to IMU must have knowledge of the program because participants have entitlements that are consistent with their level in the program, including how they are secured in the dayroom. Their level in the program also dictates which commissary products they can purchase. The use of incentives is further structured based on the advancement within the program.

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Appendix IV The Agreed Order Status Update Page 13 of 59
Facilities Management, Cermak, and DOC leadership identified physical plant inefficiencies and repairing structural defects resulted in additional modifications and caulking of the gaps. Availability of safety garments has increased. Following discussions, safety garments were placed in the Shift Commanders' office. The plan for repairs of shower partitions damaged by detainees and their modification to prevent detainees from climbing on and then jumping off these elevated surfaces is in progress.
MH continues to address issues pertaining to safety garments' deployments. MH continues to recommend the deployment while the ultimate call whether to deploy the garments belongs to DOC supervisors. Cermak considers recommending deployment of safety garments when:
1. Detainees weaponize/ have a substantial risk ofweaponizing their DOC's, bed linen, and parts of mattresses by wrapping them around their necks or otherwise inflict self-harm using the above objects to create ligatures
2. Detainees plug the toilet/are at substantial risk of plugging the toilet with their DOC's, bed linen, and parts ofmattresses.
3. Detainees tamper with fire alarm safety equipment using the said objects.
Use of safety garments for valid clinical and security indications ought to be balanced against concerns that surround use of force on the compound.
Limited space and computers make it difficult to conduct all clinical activities and charting on days when all staff is present. Psychiatrist sees detainees through a sliding window opening in the Nurses' medication dispensation room/medical triage room on the tier and with immediate access to EMR.
Staff absenteeism has been a problem. There are employees assigned to do groups from the fourth floor ofRTU during the 7-3PM shift but due to vacation and sick time, they are absent from time to time. In addition, groups may be cancelled due to medication pass, overflow detainees being transferred, power washing of cells, or behavioral issues.
The amount of Overflow P2/P3/detox patients sometimes placed in IMU overnight (mostly due to bed shortages in RTU) has been stemmed to a significant degree.
If there are any emergencies, mental health workers come to the tier during all shifts. If for some reason there is no mental health worker on during the 11 PM-7AM shift, all emergencies are seen in Urgent Care. At times, the detainees attempt to create issues in order to get to the Urgent Care area, and be transferred to Stroger Hospital for better food and painlbenzodiazepine medication, if possible. These issues include self-injurious behavior, attempted hanging, foreign body insertion/ingestion, jumping off ledges, slipping in shower, eating magic shave foam, and banging head.
One challenge is providing sufficient dayroom time as the program census grows. The team has

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AppendixN The Agreed Order Status Update Page 14 of 59
mapped out showering times for those who display different levels of advancement within the program and different deficits/behavioral problems. The hours out had to be remapped, taking into accounts varying restrictions on detainees with different advancement within the program. It was further clarified that Assessment stage detainees can only come out with other A&A detainees. They are tethered to the table at all times. Stage 1 (cuffed) and Stage 2 (no cuffs) can come out together. However, CCDOC staff has the discretion to keep detainees separate following problematic incidents. Given the structure of the program, following these recommendations has not always been easy. MH and DOC Leadership continue to train staff to remain consistent with rules and expectations.
Cermak UC staff coordinates with RTU Medical and RTU DOC staff to have them primarily assessed in the RTU Dispensary following incidents, so that movement to Cermak care is minimized.
Updates: Women's Services RTU S'h Floor and Division 4
Cermak continues to provide Psychiatric Services to the mix ofP3, P2, and SMU populations on the 5th floor ofRTU. Psychiatrists presently provide services to mostly P3 detainees, as significant numbers of detainees with P2 Level of Care were transferred to Division N. At the same time, most of the pregnant females from Division N were transferred to the 5'h floor of RTU. Dr. Briney is the Unit Director.
Division 4 houses P2 Levels female detainees in a celled setting. All the P3 detainees have been moved to RTU 5th floor. That included P3 pregnant detainees remanded to the rehabilitative program (SWJP) run by an outside Vendor (Salina and Associates). There are still almost 50 detainees =olled in the program (court ordered). DOC moves them to Division N from RTU 5th floor for therapeutic activities. There are only 5 of these detainees at this point. At the end of March Salina and Associates stopped providing services in the said program. CCSO's Office of Programmatic Services and the Office of Mental Health and Advocacy will be providing the services going forward. DOC coordinated with Cermak during the transition. The importance of sharing the same workload against the challenges of not sharing the same EMR was emphasized. Mutual roles and expectations were defined again. Agreements have been confirmed in terms of access to DHCRF process, routine and emergent services provided by Cermak staff. The mapping ofthe interagency cooperation has begun (including interdisciplinary staffing). Psychiatric Services have been provided by a Psychiatric Physician Assistant. Psychiatric presence has been expanded from 3 to 4 days a week.
Division 4- Approximately 60 P2 patients were moved from RTU to div. 4, per CCDOC. There are about 175 P2 patients in div. 4, as well as general population, protective custody, and one women's justice tier. We have seen a slight increase in self-harm attempts since P2's were moved to div. 4. Div. 4 is fully staffed with two mental health specialists who complete PC rounds twice per week, mental health clinic, mental health evaluations (psych evals), HSR, and facilitate two groups per tier per month. Enrichment programs have been implemented for P2

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and GP patients (Book Club, Theater Group, Anger Management, Yoga, Legal Aid, and sewing workshop). Superintendent Baker has been instrumental in improving multidisciplinary communications and increasing enrichment programs. There has been an increase in movement for CCDOC programming from RTU to div. 4 resulting in some missed Cermak clinic appointments. There will need to be efforts continually focused on increased communication to ensure that patient availability for appointments is consistent.
RTUHousing- Patients seem to generally prefer dorm housing. Housing units in RTU are being regularly power washed. No recent temperature complaints. Access to hygiene products and undergarments is reported to be consistent. On February 23rd CCDOC reassumed responsibility for distribution of hygiene products to all patients in RTU, including P3 level of care. Ongoing religious services are provided and CCDOC provides weekly Enrichment groups for P2 patients. A recent addition is the Mental Health Therapeutic Library created to allow patients access to books to utilize as a coping skill.
P3 intermediate MH groups - Averaging 7 hours of participation per patient per week on P3 tiers due to 50% staffing levels for three months. Additionally, all mental health specialists were rotated on 12/1/16 requiring a significant transition and training period, which impacted group hours. Intermediate mental health tiers are now fully staffed, oriented, and on track to achieve I0 hours per patient per week of patient participation. Current patient refusal rate is approximately 55%.
Special Management Unit CSMU) and Protective Custodv - Mental health rounds are completed once per week on each tier. Patients are assessed by MH within 24 hours of placement in the SMU. RTU SMU and PC are assigned a mental health specialist. RTU SMU and PC patients received approximately 8 hours for mental health groups per week. Long term P3 patients receive a monthly individual therapy session and treatment planning. Div. 4 PC (GP and P2' s) received mental health rounds twice per week.
As of April I 0, 2017, there were 7 male detainees with P3 mental health alerts being housed on the male SMU tier in Division 08 RTU and there were no female detainees with P3 mental health alerts being housed on the female SMU tier. Table I shows that for the 7 male detainees on SMU tiers, the average length of stay is 5.9 days and the longest active SMU stay is 17 days.
Table 1: Current Length of Stay for P3 Detainees in SMU Tiers in Division 08 RTU

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I Division 08 RTU Total I

ts.sl

Treatment Plans - Patients meet with their tier mental health specialist to create a "treatment goal list." Each P3 patient is discussed in MDT staffing on a regular basis. Patients receive treatment cards (also to motivate patients) and to ensure they are aware of their treatment plan. Both the patients and the entire treatment team are involved in the treatment planning process, resulting in individualized treatment plans for each P3 patient. Nearly all (95%) ofP3 treatment plans are initiated and updated on time and the quality oftreatment plans has improved. There have been recent challenges, often due to patient movement, with having the five assigned tier mental health specialists completing the treatment plans. Compliance rate has decreased from 100% to 95% since the last site visit. Outpatient (P2) treatment plans are in compliance, as they are created by psychiatrist the treating psychiatrist during clinic appointments.

Outpatient mental health (P2) Treatment Groups/ Community Groups- P2's average 1.5 hours of group per month in div. 4 and RTU. Pregnant patients are now residing in RTU. Pregnant patients participate in SWJP prenatal programming, receive two community groups per month, and P3 pregnant patients receive monthly individual mental health contacts.

Health Service Requests - Completed according to policy- Patient's receive a face to face assessment generally within 48 hours of receipt of the HSR by a MRS III. Patients are abusing the HSR process. There has been a large increase of patients making demands for specific medications. They are submitting multiple, daily requests for the same issues. Usually, "anxiety" and "I can't sleep" and "Will request this every day until you give me what I want." Community groups, HSR contacts, and P,Sych evaluations are frequently including sleep hygiene, anxiety management, and relaxation/ coping skills, but the patients are hyper-focused on receiving specific medications.

Mental Health and Psychology Clinic- A significant number ofP3 and P2 patients receive individual therapy services in RTU and in Div. 4 for more personalized treatment. Wait times have greatly improved with the increase in mental health staff.

Psych Evaluations- The RTU provides 24 hour on-site psych evaluations and consultation. We are trying to improve consultation with CCDOC to refer appropriate psych evaluations according to policy (emergent issues, use of force, placement in special management unit, and suspected or confirmed physical or sexual abuse). Unit Director periodically attends roll call to discuss psych evaluations and referrals.

Individual Therapv Sessions - Each P3 patient is assigned to meet with her tier mental health specialist monthly for an individual mental health contact. One challenge in the consistency of these sessions has been security moving patients to different tiers.

Linkage and Expressive Arts -We continue to focus expressive arts and linkage services on P3 patients. P2's receive limited linkage services and discharge medications.

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Hvgiene- Hygiene has improved with P3 patients. Rise and shine program occurs five days per week. Patients displaying ongoing, serious hygiene concerns (generally psychotic) are discussed in MDT clinical staffing and are admitted to the psychiatric special care unit for increased support and a humanitarian shower (Non-aggressive patients).
Self-Harm - Womens' Services has a very low self-harm rate. Self-injuries that do occur are most often housed in segregation. We have seen some increase in self-injury in the SMU (P3 and very stable P2's), as they believe it will get them out of segregation and placed back on a tier. There has also been a small increase since P2's moved to div. 4.
Additional Challenges:
Patient Motivation - Mental health facilitates a movie discussion group for treatment compliant patients every two weeks. We are also providing a standardized letter of participation monthly for patients attending 75% of recommended treatment groups. Few women (15%) are receiving the letter of participation due to lack of consistent attendance. Long-term patients (particularly 5F) want new treatment videos and materials, reporting that they are bored. Despite ongoing and prior efforts and external motivators, the staff finds that only the women who are intrinsically motivated to participate in treatment are attending groups. The remaining patients enjoy sleeping and socializing on the tier.
Concerns About Staff- Some complaints have been received about specific mental health staffin terms of too frequently showing videos for group or not being as respectful as they should. Such issues have been addressed in individual and group supervision and resulted in a staff person being assigned different job duties.
Mental health has expressed concerns to CCDOC administration about the lack of available officers and officers leaving their post, creating a safety issue and barrier to providing mental health treatment. Additionally, CCDOC has been notified of specific security staff displaying rude and unprofessional behavior, in addition to being disruptive to mental health treatment services. Supt. Yoksoulian has been open to feedback from mental health regarding concerns.
Abusing Medications -Concern regarding patients trying to be prescribed as much medication as possible and having issues with patients hoarding and abusing the medications continues to be a challenge. The interagency treatment team works diligently to communicate about and address these issues.
Compound Special Management Units:
Compound SMU housing was assessed on 3/28/2017 with the following data captured: • Compound Census as of03/28/2017: 7,598 • RTU SMU and PC Census 03/28/2017: 39 (13 in disciplinary SMU, 26 of them are in Protective Custody );

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• Out of39 detainees- 9 (23%) are P2's and 30 (76%) are P3's ( 0.51% of the total compound detainee population are housed in RTU SMU)
• Total number ofP3's in SMU (excluding Protective Custody): 6 ( 0.07% ofthe total compound detainee population )
• Division VI SMU Census (all P2's): 59 (55 of them are in Protective Custody) • Division IX SMU Census (all P2's): 84 ( 46 of them are in Protective Custody) • Division IV SMU Census (all P2's): 7 (all in protective custody) • Total SMU population on the compound (including Protective Custody Population) 189
(2.4% ofthe detainee population) • Total SMU population on the compound (excluding Protective Custody Population) 55
(0.72% ofthe detainee population) • SMU settings: DOC and Cermak staff work together on overcoming inherently lower
accessibility of patients to care; the overriding principle remains being able to provide essential psychiatric and mental health services regardless of housing; very helpful was the establishments and of the Compound wide Access to Care Workgroup with the participation of the Cermak operational leadership and most senior CCDOC executive leadership with the focus ( as the first priority on further improving access to care in Division IX which houses significant behaviorally problematic/institutionally disruptive P2 detainees in various SMU units) • The LengthofStayinRTU SMU CQI study was conducted (APPENDIX) • Cermak staff continues to work on modifYing conditions of confinement for SMU populations. For RTU SA (Special Management Unit), the female SMU housing P3/P2 women, the four dates chosen at random were December 13th and 28th, 2016, and January 5th and 19th, 2017. The average length of stay for the 11 detainees in SMU on December 13th was 5.9 days, and there was only a single outlier (at 21 days) on that date. The subsequent three dates all revealed longer LOSs, averaging 13.2 days overall. There were two outliers on each of these three dates, ranging from 30 to 60 days. The CQI SMU Length of Stay Study can be found in the PDF Appendix. • Cermak continues to strive to modifY conditions of confinement for those who are housed on 4A (SMU male tier). For RTU 4A, on December 13th, the 12 male detainees housed there averaged 21.3 days, with six outliers ranging from 17 to 53 days. The average LOS for the subsequent three dates (analyzed in the CQI study referenced below) fell to 12.4 days. For the three later dates, there were a total of eight outliers overall, with lengths of stay ranging between 119 and 82 days. The CQI SMU Length of Stay Study can be found in the PDF Appendix. • Modification of conditions of confmement for those individuals with Serious Mental illness whose time in SMU exceeds 14 days would consist of providing more out of cell time to them. DOC Disciplinary Unit continues to issue tickets for P3 that do not exceed 14 days. Tickets do not always run concurrently. Cermak continues to provide structured therapeutic programming for SMI detainees in SMU 4A, further described in the updates. Detainees remain tethered to stationary furniture during out of cell group structured therapy/activities. Cermak will continue to target 10 hours of structured activities weekly/! 0 hours unstructured activities weekly provided to these detainees. Programming

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activities on the male tier have been at times affected by institutionally disruptive detainees. Detainees with higher level of functioning, when introduced into the milieu with more regressed poorly functioning patients, have a tendency to adversely influence more regressed individuals. The importance ofnot introducing potentially predatory detainees into the RTU SMU environment is recognized. • Cermak :MH Department furnishes SMU detainees with the following services:
o SMU rounds weekly (in addition to weekly PCS rounds) o Psychiatry appointments (regularly scheduled and walk ins) o Individual Behavioral Management Treatment Plans o Other essential services -individual supportive counseling, access to emergency
and routine care as per DHCR process, crisis intervention, etc. (commensurate with their level of care) • The Interagency process designed to streamline services in SMU Units in Division 9 was finalized in February 2017. Different Services in the following order- Disciplinary Board Hearings, Interagency Huddles, Nursing Triage, and :MH /Psychiatry Clinics- were lined up and patient movement was coordinated with ERT Supervisors and Divisional Shift Commanders. New space was dedicated on 1S. A storage room was repurposed to allow seeing detainees for :MH and Psychiatry appointments. A desk with EMR computer, patient chair, a wall ring (to tether detainees to) were all installed to enhance security during sessions. Significant effort is made to reduce SMU patients' movement within the building and, even more importantly, outside the building. What causes self-injury and acting out is multifactorial and, yet, it is believed that many detainees engage in acts of self-harm and other acting out in order to secure movement and break the monotony of SMU confinement. Telehealth continues to be utilized in order to utilize the incentive that movement to appointments represents to many detainees in SMU. Additionally, reducing the frequency and length of movement reduces the number ofincidents of the use of force
Correctional Programming in Special Management Units: Effective January 2016, the DOC discontinued the use of administrative segregation. Additionally, in January 2016 the DOC identified detainees that had been causing the most disruption to the compound and moved them to one tier in Division 9 (Tier IF). Many of these inmates were affiliated with the newly formed 'Savage Life' gang. The DOC staffed the unit with the Emergency Response Team (ERT). Expectations, unit rules and consequences ofrule-breaking behavior were articulated in writing to each detainee. In March 2016, this special management concept was expanded to include Division 10 Tier 1A. In February and March 2016, the DOC reduced the number of detainees in special management, reducing the general population special management units (those in Divisions 6, 9 and 10) from 8 to 5 living units. In April 2016, the DOC piloted a revised procedure for restrictive housing in Division 9 to allow detainees in restrictive housing to have 1.5 hours out of cell each day. In May 2016, the DOC transferred all general population restrictive housing units to Division 9 and initiated Special Management Unit (SMU) housing. SMU tiers replaced disciplinary segregation and allowed detainees to receive at least 3 hours out of cell. All detainees are secured using a waist restraint system or security cuffs and are

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monitored by an increased number of Officers who engage with the detainees on the tier. Detainees with recent violent infractions are often handcuffed to the dayroom tables as an enhanced security measure. Detainees in the SMU tiers may also be handcuffed to the wall while using the telephones. General population SMU tiers are staffed with at least 3 Officers and mental health SMU tiers are staffed with at least 2 Officers because the census is lower. All tiers allow for at least 2 detainees to interact in the dayroom at a time, though several of the tiers allow 8-12 detainees in the dayroom at a time depending on the makeup of the tier. The presence of correctional staff on the tier allows for increased positive engagement between correctional staff and detainees. It was important for the DOC to effect positive behavioral change among the detainees by encouraging the correctional staff to model such behavior. The tiers are managed by a combination of the DOC's ERT and Division 9 staff. Some of the most problematic detainees have successfully matriculated through the general population SMU and been allowed the opportunity to participate in divisional programs. One detainee that was heavily involved in the Savage Life gang and charged with several violent offenses had over I00 incidents of fights, batteries to staff and self-harm from July 2015 until the end of October 2016. Following encouragement from the ERT and Division 9 staff, the detainee's behavior began to shift and staff noted the detainee's desire to make behavioral improvements. The Division's Superintendent arranged for the detainee to have weekly meetings with two religious programming volunteers. At the advisement of the ERT staff, DOC leadership approved the detainee to be transferred from SMU to a progranuning tier where he could continue his involvement in the religious services program. In the following three months the detainee had no incidents of battery to staff, only one fight and a more than 80% decrease in self-harm incidents.
Updates: Division 2 Dorm 2/minimum and medium securitv
Population 390
Division Two- Dorm Two houses P-2 and M2 (outpatient level of care) patients within a dorm setting. There are ten dorms over three floors, with a census of approximately 44-48 detainees in each tier. It includes detainees with minimum and medium security classification. Services are maintained without significant changes. MHTC detainees are housed in the V house. Dr. Kaniuk is the Unit Director.
Telepsychiatry Clinic continues to provide reliable coverage for this Division and remains one of the strongest assignments in terms of productivity and meeting departmental expectations. Dr. Ward sees patients on a daily basis, with a combination of new evaluations and follow-ups. Dr. Marri is in Division Two- Dorm Two for two full days and usually sees detainees who need translation services.
Division Two- Dorm Two houses P-2 and M2 (outpatient level of care) patients within a dorm setting. There are ten dorms over three floors, with a census of approximately 44-48 detainees in each tier. It includes detainees with minimum and medium security classification. A dorm setting makes it easier for detainees to talk to the staff, since they are often within proximity of

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the detainees. As a result of increased accessibility to mental health staff some of the requests are not related to mental health. Thus, the limited staff can become overwhelmed. Since there are only two interview rooms on the second floor (and one is being used by telepsychiatry Monday through Friday), it becomes more difficult to see detainees in a private setting. Quite often staff have to interview detainees outside the tier in any available space.
There is one employee assigned during the 7-3PM (Tuesday through Saturday) shift and one during the 3-llPM (Sunday through Thursday) shift. During the llPM-7AM shift, all emergencies are seen in Urgent Care. Groups are conducted on a weekly basis in all ten tiers. They are composed of two parts: community issues and therapeutic intervention. The types of groups conducted are anger management, substance abuse, domestic violence, criminogenic thinking, and depression.
Security refers individuals who request an evaluation or have a question, as well as those who display behavior problems. This is done formally (Inter-Agency Health Inquiry) and informally. The mental health staff, along with the CRW's, meet with Supt. Martinez on a weekly basis.
There is a psychology clinic scheduled for Tuesday mornings. There are no problems seeing detainees in this clinic. Mental health clinic occurs on Wednesday and Thursday mornings. One mental health specialist is assigned to this clinic and it runs rather smoothly.
The nursing staff processes HSRF forms before giving them to mental health staff. On occasion, there is a delay in processing the forms. The detainees who write these requests are seen by the mental health staff (MRS III or psychologist) in a timely manner.
There is a medical social worker assigned to work in the building. He addresses family issues, discharge medications, and provides linkage services to community agencies.
Updates: Division 6/Minimum and medium security
Population 236
Division Six houses P2 and M2 (outpatient level of care) patients, along with GP (General Population) detainees, and transgender detainees. The Protective Custody tiers and the Westcare substance abuse program (2-B) house many of the P2 detainees, though others are scattered throughout the building. The changes in the Westcare program (January 2017) decreasing from three tiers to one resulted in an increase in requests for mental health evaluations. We suspect that detainees who were participating in programming during the week engaged in increased support seeking. The PC population includes detainees with special accommodations. There is one SMU tier in the building (2-D), which opened up on January 30, 2017.
There are now two mental health specialists assigned during the 3-llPM shift. This began on

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March 7, 2017. Groups are scheduled for Tuesday and Wednesday (one daily) and security provides an escort. The groups contain two components: co=unity milieu issues and therapy. The therapy group topics include substance abuse, anger management, criminogenic thinking, domestic violence, and depression.
Security refers individuals who request an evaluation or have a question, as well as those who display behavior problems. This is done formally (Inter-Agency Health Inquiry) and informally. The unit director (psychologist) and other disciplines meet with Supt. Beachem on a weekly basis. There are multi-disciplinary staffings scheduled twice a month.
As the population ofP2 detainees grew, Psychiatry allocations were increased to acco=odate the increased need. Presently a Telepsychiatric clinic is open on both shifts on Thursdays in addition to Psychiatry on site clinic opened on Fridays. If there are additional appointments needed, they are seen in Urgent Care on Thursday afternoons, from 2-4PM. Challenges can arise ifboth Protective Custody detainees and other individuals have to see psychiatry in Urgent Care. This means that security must bring one group at a time. On many occasions, the second group comes too late and misses the appointment. There is a psychology clinic scheduled on Monday mornings. Security brings the detainees on a timely basis. Mental health clinic occurs during the 3-llPM shift on Sunday, Monday, and Thursday. There have been no difficulties reported about this clinic. SMU rounds occur on Tuesdays and SMU groups are conducted there on Thursdays. The nursing staff processes HSRF forms before giving them to mental health staff. During the morning shift, the forms are faxed to Urgent Care and emergencies are seen as soon as possible. There is a medical social worker assigned to work in the building. He addresses family issues, discharge medications, and provides linkage services to co=unity agencies. Dr. Kaniuk is the Unit Director.
Updates: Division 9/Maximum and medium security
Population 201
Division 9 houses P-2 and M-2 (outpatient level of care) patients, along with General Population detainees. Total population absorbs several Special Management Tiers in Division 9. That included 3H and 3G (Protective custody) and IE, lF,lG,lH (Special Management Tiers). IF remains a tier which houses detainees that represent institutional threat/disruption as well as staff assault. This tier is afforded enhanced security parameters. Supervision of detainees is shared between ERT (Emergency Response Team) and Divisional DOC frontline staff. There are three Providers dedicated to the provision of Psychiatric services in Division 9. Psychiatric allocations are listed elsewhere. The number of detainees in lE,lF, lG, IE fluctuates to some degree and the majority of patients, following the completion of their disciplinary tickets in SMU remain in Division 9. All three Psychiatrists follow detainees in SMU and outside of those Units. Unit Director is Dr. Augustine.
The Patient Safety and Enhanced Security Guidelines for patients who present with self-harm

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(Foreign Body-ingestion/ insertion and pill ingestion) in Division IX were developed between Cermak and DOC Divisional/ DOC Cermak staff. They are designed to complement the enhanced security parameters and reduce the amount of disruption of operations. Specifically, the way detainees are staged outside of traditionally " desirable" areas in Cermak where these detainees congregate with others exchanging information and engaging in fights, was outlined and divisional Cermak /DOC staff collaborates using the following outline:
o Divisional staff to confer with the Urgent Care provider before transferring frequent "foreign body self-injury" and "pill ingestion" patients to the Urgent Care.
o The Urgent Care provider and nurse should discuss the details of the case, vitals and assessment of patient, and treatment plan options on a case by case basis. They should feel free to confer with the House Supervisor or PCC Leadership, if guidance is needed.
o Paying close attention to the security alerts assigned to a patient. Proceed with caution when assessing patients with "aggressive" alerts- "Spitler" (must be seen with a spit mask applied by DOC), "313"- masturbators, "Crine/Feces projectors", "Aggressive toward staff" etc. Coordinate transfers to the Urgent care with CCDOC.
o Please notify MH of patients returning from an outside ER or hospital after a self-harm incident.
Analogous Guidelines for Management of Patients after Foreign Body Ingestion have been developed as a result of a collaborative effort between CCDOC, Department of External Operations, Cermak Administration, John Stroger Hospital Risk Management Department, JSH Emergency Room staff, and JSH Gil Internal Medicine Department. These guidelines operationalize transfers, observation, alimentation, and treatment ofpatients engaging in frequent self-injurious behavior, for non-suicidal reasons.
It is proposed to utilize presently existing Telehealth rooms on 2N and 2S (Division 9) as MH offices. DOC and Cermak continue to work on improving access to "not regularly scheduled" care in Division 9. Presently, in addition to Cermak Movement List generated by Scheduling for all Cermak clinics and sent to DOC Divisional Leadership the day before, during morning huddles with Divisional DOC Leadership, lists of add on patients are generated and shared with DOC Supervisors/Shift Supervisors. Cermak Operational Leadership and CCDOC Executive Leadership worked out a pilot project designed to further improve the process and interagency interactions in Division 9. Designed to go live in the first days of April2017, the following process will be utilized:
• The presently existing movement list will be discontinued • An email will be generated by Cerner at 6 am to list all the patients scheduled for valid
PCC, Dental, MH, and Psychiatry Clinics • The said list will be emailed to the DOC email group including Shift Commanders • As clinics begin and pts get moved to their appointments, AA's will proceed to check
them in Cerner • Cerner will continue generating periodic ( q30 minutes) updates to the list with the names

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of those who yet to arrive to their scheduled appointments • These updates will continue to be generated and shared with DOC group until the clinics
are over • A final wrap around list( summary) of the clinics' list will be generated at the end of a
clinic and accompanied with the CSV's files also shared with DOC Supervisors • Presently, the old process will continue to be utilized to have" unscheduled" detainees
moved to clinics( generating list in morning huddles and otherwise and sharing them via email with Shift Commanders)
A separate CQI Access to Care Study for Division 9 was generated and is available in the PDF Appendix.
Updates: Division 10/Maximum and medium security
Population 465
Division 10 houses Maximum and Medium security P2 and M2 detainees. Unit Director is Dr. Augustine. Notably, due to the efforts exerted by the Cermak and CCSO Bed Control Departments, there are no P3 detainees in the Division. Additionally, there are two Protective Custody Units (1 C and 2C) in the Division. There is one Full time Psychiatrist and two Locums Psychiatrists in Division X. Allocations are discussed elsewhere. Telepsychiatry clinic is open in Division X three days and continues to provide valuable supplementation to existing employed PTE's. In March 2017 the second Psychiatry workstation became Telepsychiatry compatible and now Division X can provide Psychiatry Services using two Telepsychiatrists at remote sites at the same time. Division X continues to utilize a dedicated Locums Telepsychiatry Clinic attendant. Access to care issues prompted a separate CQI No Shows study which can be found in the PDF Appendix.
Updates: Combined Division 9/10
Since the last summary the following services continue to be provided by Mental Health Specialists and one psychologist on Division 9, Super Maximum, and on Division 10, Maximum: evaluations for mental health conditions, psychological evaluations and assessments for suicidal risks and assessments of detainees to determine if there are concerns regarding placement in Special Management Units by CCDOC. This clinical team also provides therapeutic services which includes specialist clinics, group therapy, treatment plans, community meetings, weekly Special Management Unit Rounds, crisis intervention and processing of detainees mental health needs submitted via Health Service Requests and Inter-Agency Health Inquiries forms.
There has been an increase of Mental Health Specialist from two to three in Division 9, one on the am shift, (7 am -3 pm) and two on the 3-11 pm shift. They provide services to 24 Tiers. Currently, there are six Mental Health Specialists in Division 10, four on the am shift, 7 am -3 pm and two on the 3 pm -11 pm shift. They provide services to 16 Tiers. All urgent mental health needs that

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occur on the 11pm- 7am shift are addressed by the Urgent Care staff.
Accomplishments are reflected in weekly provision of the above listed services and weekly provision of: Mental Health Specialist Clinics six days per week on Division 10 and seven days per week on Division 9, weekly Psychology Clinic on Mondays in Division 9 and on Fridays in Division 10, weekly Psychiatry Clinics on Division 9
Groups are conducted by Dr. Brian Waxler, Psychologist, on Division 9/lE on the first and third Tuesdays ofthe month.
After being suspended in August, 2016 (due to security concerns), Groups/Community Meetings resumed in Division 10 on October 19th. When groups resumed in Division 10, there were some challenges in having consistent supervision available. However, with the support of the Supt. Walsh and Director Reyes there has been gradual improvement. Since the last summary in October 2016 a total of97 groups were conducted (Nov.-Feb.).
The challenge oflack of office space for Mental Health Specialists in Division 9 was resolved.
Mental Health leadership and staff submitted a proposal for a Therapeutic Tier in Division 10 on January 20th, 2017. The proposal to create the tier was an action plan to address the augmented need of a subset of the outpatient population and to provide a therapeutic equivalent to RTU for patients who have demonstrated a pattern of behaviors to remain in RTU when their level of care was stepped down. Documents describing the Therapeutic tier can be found in the Appendix. CCDOC approved the Therapeutic Tier during the week of March 13th and patient transfers began later that week. Cermak staff makes requests to CCDOC for transfers into the tier on a "rolling admission basis". CCDOC vets the requested patients for security related issues and moves those patients that are able to move to the tier. The program is voluntary, so patients do have the right to refuse. Cermak staff discuss the referral for the program with the patients to minimize refusal rates. Due to CCDOC bed space, we have not been able to make the tier a "closed" therapeutic milieu. Patients who are not referred to the program are housed on the tier and are sometimes disruptive to the programming.
One Mental Health Specialist has primary assigmnent for the Therapeutic Tier, 2B Division 10. This MHS coordinates with the psychologist and other providers to schedule, facilitate and enhance services to the Therapeutic Tier. Mental Health Staffbegan providing services on the Therapeutic Tier on March 19th, 2017. Further information about the programming on the tier can be found in the Appendix.
Mental Health Leadership and staffin Division 9 presented a proposal in January 2017 for a Behavior Management Unit Pilot Project to address identified detainees who are not diagnosed with severe mental illness but displayed chronic patterns of engaging in self-injurious behaviors, suicidal gestures and threats, as well as aggression towards others, sexually inappropriateness, and create other operational and institutional disruption. An assessment of small group of

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identified detainees was completed. Several multidisciplinary meetings were held and a draft proposal, including drafted behavior management plans, was submitted on February 7th, 2017 for CCDOC's approval. Approval is pending.
The following challenges impact the delivery ofmental health services on Divisions 9 and 10: The office space available for provision of Mental Health services on Division 10 continues to pose a potential risk due to the small space that results in physically close and uncomfortable proximity between staff and detainee.
On Division 9 the challenge of achieving 100% compliance in seeing detainees who are placed in Special Management Units (SMU) by CCDOC continues. The following factors continue to impact this compliance: sometimes there are no movement of detainees due to safety concerns, detainees refused to be seen, MHS staff are not always informed when a detainee is being placed in SMU or when the detainee is removed and returned after 30 days/24 hours out compliance, detainees are not referred when they are returned from outlying counties and hospitals.
Other challenges in Division 9 are being addressed by the access to care work group. Line staff have indicated that a shortage of CCDOC staff needed for escort and safety incidents have impacted the movement of detainees in need of mental health services. The Chief Psychologist conducted a QI study to review this concern that can be found in the Appendix. It is hoped that data collected regarding factors that impact access to care in Division 9 and the current pilot project will result in improvement in this area. Mental health staff are now scheduling all nonurgent health service request forms to assist in streamlining of scheduling mental health movement as part of this pilot.
Recommendations:
The increase in staff will help to enhance provision of mental health services in Divisions 9 and 10.
A proposal for a more appropriate office space needs to be identified to minimize the safety risks posed by the close proximity of staff to patient in Division 10.
Mental health and CCDOC will continue to dialogue and work to address compliance in regard to SMU admission evaluations.
Mental Health Transition Center: The Sheriff's Office Mental Health Transition Center (MHTC) has increased its participant caseload to about 150 participants. It remains a day treatment program at this time.
April2017 Metzner assessment: Substantial achieved compliance has been made in offering at least 10 hours per week of structured therapeutic activities for inmates with a P3 classification, which is a significant accomplishment.

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Since the November 2016 site assessment, RTU Male Services has continued to focus on expanding services to the protective custody tier, maintaining compliance with treatment plan timelines and coordinating with CCDOC to minimize group cancellations.
It is encouraging that the only overflow housing unit for P3 inmates is now located in the RTU and the length of stay in the overflow housing unit was reported to be not long. It is also encouraging that a "therapeutic" housing unit has been opened in Division 10 to serve as a transition for inmates being discharged from the RTU. This housing unit was opened during March2017.
The RTU inmates' access to the patio has significantly increased for both male and female inmates. Funding has reportedly been obtained to winterize several of these patios by the end of 2017. In addition, an outside exercise yard is being constructed adjacent to the RTU with an optimistic date of completion being this summer.
During the morning of Aprilll, 2017 I observed community meetings in RTU units 5B (a medium-maximum security female dormitory) and 4H (a minimum-medium security male dormitory), which were competently managed by the mental health specialists. I also interviewed inmates in a community-like setting in units 4C (aminimum-medinm security male dorm), 4F (a medium-maximum security male dormitory) and 5F (a maximum security female dormitory). Inmates were almost uniformly in agreement that the offered mental health groups were very beneficial to them with many of these groups reportedly being offered in a group room off the unit. Their report regarding access to outdoor patios and the gymnasium were consistent with the information provided in the status update section. Medication continuity issues were not present. Unlike many others site assessments, when asked about their prior experiences in either Cermak 2N or 2W housing units, inmates described much more positive treatment experiences. Most inmates reported meeting with the psychiatrist on at least a monthly basis. Timely access to the psychiatrist via the health care request process was variable. Many inmates were aware of the discharge planning services available to them.
Unlike other site visits, issues voiced by inmates related to conditions of confinement, such as access to cleaning supplies and the quality of the food, were minimal.
During the afternoon of Aprilll, 2017 I observed a treatment team staffing for the male RTU program. The staffing was attended by the relevant clinicians with very good multidisciplinary input provided. Inmates receiving their 30 day treatment plan were interviewed as part of the staffing process.
The male Special Management Unit (SMU) is located on the second floor of the RTU. This specialized 10 bed capacity program, designed to provide increased structure and support for mentally ill detainees who have demonstrated significant problems in their functioning, continues to evolve in a very positive manner. I observed the mental health rounding process in the SMU during the afternoon of April 11, 2017, which was done in a very competent fashion by

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Appendix IV The Agreed Order Status Update Page28 of59
the mental health specialist. During the rounding process four imnates, all handcuffed, had unstructured out of cell time in the dayroom.
During the morning of April 11, 2017 I observed an out of cell group therapy being offered to female SMU inmates. Five inmates were handcuffed at two spider tables and one inmate participated through the food slot in her cell. Despite the large number of persons watching this process, the mental health specialist was able to successfully engage the imnates in a useful therapeutic activity.
I continue to have concerns relevant to psychiatric staffing in the RTU, which will be addressed in a later section (see 59.f).
P2 level of care inmates in Division II reported having increased access to an outdoor yard and/or downstairs recreational area. Many of these inmates were emolled in the CCDOC's Mental Health Transition Center program that provided daily programming, which was very well received by the involved inmates. In general, these inmates had much less complaints regarding their conditions of confinement related, in large part, to the above progrannning. These P2 inmates reported that they generally saw a psychiatrist on about a monthly basis via the telepsychiatry process. Continuity of medication issues were reported to be uncommon events.
During the morning of Aprill2, 2017, I observed the mental health rounding process within the SMU located within Division 9, which was done in a very competent manner by the mental health specialist. About 10 inmates were in the dayroom, all handcuffed, as part of their daily out of cell unstructured time. Four correctional officers were also present in the dayroom. The atmosphere within the SMU was reasonably relaxed.
I also met with inmates in a community meeting-like setting within Division 10 in four housing units (2B, 4B, 1C and 4A). Unit 2B, which is the ''therapeutic" P2 housing unit, clearly had established a more therapeutic milieu as compared to most other Division 10 housing units. Inmates in the other housing units visited described mental health treatment to primarily consist of medication management with minimal access to monthly community meetings and/or small group therapies. Continuity of medication issues was not a problem in these units. Inmates reported access to the gymnasium on a 2-3 times per week basis. As compared to prior site visits, the tension level within these units were markedly reduced.
A Compound-wide Access to Care Workgroup has been established with the participation of the Cermak operational leadership and most senior CCDOC executive leadership. This workgroup is focusing as the first priority on further improving access to care in Division 9, which houses significant behaviorally problematic/institutionally disruptive P2 detainees in various SMU units. Improvements have already been made in reducing the number of "no shows" for scheduled appointments. The results of this focus will eventually have significance to other divisions within CCDOC.

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Appendix IV The Agreed Order Status Update Page29 of 59

CCDOC remains a leader nationally in reducing the use of housing units that are basically locked down (i.e., segregation housing) by significantly changing the conditions of confinement in such settings, decreasing the numbers of inmates classified to such settings and providing programs that should help many inmates work their way to lesser restrictive housing units. During April 10,2017, there were a total of 154 inmates housed in a SMU, which represented about 2% of the total CCDOC population.

Significant improvement in the context ofthe RTU therapeutic milieu and conditions of confinement (e.g., significantly improved inmate access to off unit recreational time) throughout the compound were obvious during this site assessment. Opening of the planned outdoor RTU recreational yard will be a major accomplishment and will have a very positive impact on the milieu.

Recommendations: Continue to closely monitor the out of cell structured therapeutic time being offered to and used by RTU inmates as well as their access to outdoor patio and/or outdoor yards. Consider changing the threshold for therapy achievement letters to averaging 10 hours of participation per week in structured therapeutic activities.

See provision 59.f.

e.

Cermak shall ensure that treatment plans adequately address inmates'

serious mental health needs and that the plans contain interventions specifically

tailored to the inmates' diagnoses.

Compliance Assessment: Substantial compliance (4/17)

Factual Findings:

April2017 Cermak Status Update

Please see Appendix for Treatment Plan QI Audits for each level of care.

Separate CQI study ofP2 Level of Care detainees receiving no medications can be found in the PDF Appendix.

Intensive Management Unit (IMU) staff generates Multidisciplinary Treatment Plans called SelfManagement Housing Plans for each individual patient housed in IMU with weekly updates.

Interagency Behavioral Management Plans continue to be developed as needed by Unit Directors in concert the Chief Psychologist, the Chief Psychiatrist, and the full multidisciplinary team for more complex or difficult cases throughout the compound.

• P4 (Psychiatric Special Care Units): Psychiatric Special Care Units patients have

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 57 of 89 PageID #:5471
Appendix IV The Agreed Order Status Update Page 30 of 59
completed treatment plans within 72 hours of admission to the Psychiatric Special Care Unit (PSCU) by QMHP and the Treatment Team with a review and update triggered by changes in acuity (such as placement in therapeutic restraints or administration of emergency medications) and failure to achieve goals, but no less frequently than weekly. • Once patients within PSCU's are determined to require subacute level of care, with regard to the frequency ofTreatment Plan reviews, they will have their Plans reviewed by QMHP and the Treatment Team every 30 days for two months. After that, patients within PSCU's requiring chronic level of care will have their treatment plans reviewed no less frequently then every 90 days by QMHP and the Treatment Team from that point forward. • P3(Intermediate Care): Mental Health Intermediate/residential level of care patients have completed treatment plans by a QMHP within 30 days of admission to that Level of Care, with review and update at least every 90 days thereafter. • P2(0utpatient Care): Mental Health Outpatient level of care patients have completed treatment plans by a QMHP (Psychiatrists) within 45 days of admission to that Level of Care, with review and update at least annually thereafter. New individualized free standing Master Treatment Plan Templates have been identified in Cemer. Although they were originally tailored to JTDC (Juvenile Temporary Detention Center) populations, Cermak started using them at CCDOC, while IT is modifying them to meet the needs of CCDOC campus. The new Master Treatment Plans will allow to create more individualized and focused plans as they incorporate: reflection of collaboration with the inmate, frequency of follow up for evaluation and adjustment of treatment modalities, referrals for lab work for medication monitoring, instructions about adaptation to the correctional environment, documentation of treatment goals and objectives, notations of clinical progress. It is of note, that Cermak started the interim process ofthe Rx Plan modification while preparing to unroll already purchased Behavioral Health Cemer Module. Estimated time ofinception is summer 2017. The Behavioral Health Cemer module promises to greatly increase the efficiency and capabilities ofEMR as it relates to providing care/treatment planning on CCDOC campus. Chief ofPsychiatry introduced the new Master Treatment Plan Template in January 2017. Psychiatrists working in P2 setting received training and directed to start using the new Template. It is still allowable to supplement that Template with the Rx plan pertaining entries within the powemotes where Providers chart. The ultimate goal remains is to create individualized Master Treatment Plans for every patient in P2 Level of care within the requisite time frame while addressing detainees' serious mental health needs and have them updated three times a year/when goals are failed (current Policy requires annual updates). The most recent number of Master Treatment across the compound as of 3/30/2017 is 61 0(36%), while the number of detainees on MH caseload in P2 Level of care is 1671. As a point of reference, as of2/ 28/2017 the number of Master Treatment Plans was 480 (30%) with P2 count -1579. In absolute numbers, 130 Master Treatment Plans were created in the month of March. Given the fact that the project was launched in January 2017, this is a

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AppendixN The Agreed Order Status Update Page 31 of 59

significant progress and Psychiatry is steadily increasing the number of Master Treatment Plans.
Cermak collected data on the number ofP2 Level of Care Detainees who receive no medications. It is recognized that the time expenditure and complexity of treatment management is decreased for these detainees.
ALL ACTIVE P2 ALERTS FOR UNIQUE PATIENTS ON 3.30.2017

HAS AT

HAS

HAS NO PSYCH

LEAST 1 DIPHENHYDRAMINE

MEDSANDNO

3/30/2017 PSYCH

TOTAL BUT NO OTHER PSYCH DIPHENHYDRAMINE

%

MED?

MEDS?

ORDERS

02D2

327

12

04

147

1

06

175

4

RTU2

12

0

RTU3

65

1

RTU4

4

0

RTUS

34

1

08-CM2N

2

0

08-CM2W

0

0

08-CM3E

2

0

08-CM3N

7

0

08-CM3S

1

0

08-CM3W

6

0

09

147

8

10

367

36

50

389 21%

23

171

9%

64

243 13%

1

13

1%

11

77

4%

2

6

0%

9

44

2%

1

3

0%

1

1

0%

0

2

0%

1

8

0%

1

2

0%

1

7

0%

43

198 11%

43

446 24%

Aggregate data shows that 246 (14%) P2 Level of Care patients receive no psychotropics. Total Number ofP2 patients as of3/30/2017 is 1,671. Divisional breakdowo is below:

2D2 15% Div. N 15.4% Div. VI36% Div. IX29% Div. X 11%

April2017 Metzner assessment: A QI study indicated that 92% ofthe 50 treatment plans

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AppendixN The Agreed Order Status Update Page 32 of 59

reviewed (a combination ofRTP and acute care level of mental health care) were completed in a timely fashion. Problems were found in timely completion of updated acute care P4 treatment plan reviews. The quality of treatment plans continued to improve as a result of the implementation of the new treatment plan template for P2 inmates.

Recommendations: Continue to QI the above, with particular attention to treatment plan updates of acute care inmates.

f.

Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates'

serious mental health needs and ensure that psychiatrists see inmates in a

timely manner.

Compliance Assessment: Substantial compliance (ll/l6)

Factual Findings:

April2017 Cermak Status Update

Vacancies.

POSITION TITLE
Divisional Chief of Psychiatry Associate Director of Correctional Psychiatry FT Psychiatrist PT Psychiatrist PT Consultant Chief Psychologist Psychologist Physician Assistant Social Worker Mental Health Director Art Therapist MRS Administrative Assistant

ACCOUNT #

VACANT

FILLED

SUM

% VACANT

110

0

1

1

0.0%

110

1

0

1

100%

110

4

11

15

26.6%

133

2

3

5

40%

155

2

1

3

66.7%

110

0

1

1

0.0%

110

0
.J

7

10

30%

110

0

2

2

0%

110

1

6

7

14.2%

110

0

1

1

0.0%

110

0

3

3

25%

110

4

66

70

5.7%

110

0

1

1

0.0%

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Appendix IV The Agreed Order Status Update Page 33 of 59

Locums Psychiatrist Locums Medical Assistant
TOTAL

2

2

0.0%

2

2

0.0%

17

119 14.2%

*Of note that the MHS vacancy rate calculations do not include the 14 additional positions just added for the 2017 FE. These positions have been posted in January. Recruitment efforts are ongoing.
Full Time Equivalents for Psychiatry and Psychology.

FTE's Psychiatry April2017

Chair (1)

1.0

Attending Psychiatrists

10.8

Bednarz, McNeal, Haq, Miller, Kartan)

Psychiatric PA (2)

2.0

Psychiatrists (133 acct)

1.0

Consulting Psychiatrist

0.3

Psychiatrist Locums

1.0

(Kelner) (Advani, Howard, Marri 0.8, Menezes, Paschos, Ward,
(Balawender, Greiner) (Lassen, Chinweze, Ramie) (Binius) (Garb, Pandit)

Total Functional FTE

FTE's Psychologists April2017

Chief Psychologist (1)

1.0

Psychologists (10)

7.0

(K.Key) (Briney, Kaniuk, Waxler, Sillitti, Nunez, Augustine, Butler)

Total Functional FTE
As of April 2017 Functional Vacancy Rate (FVR): # offulltime positions/FTE's- #filled full time positions/FTE's- hours paid Acct. 133 ( part time) - hours paid Acct. 155( part time) - hours paid vendors( Locums)- hours paid overtime/moonlight- supplement by mgmt. =1.8%

IfPhysician Assistant Positions/PTE's are factored in- FVR in January 2017 is in the negative territory. OT/Locums represent 1.1 FTE

Psychiatry Allocations. Direct service hours and participation in MDT meetings constitute 100% ofFTE's hours.

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AppendixN The Agreed Order Status Update Page 34 of 59

•Mental Health Staffing -April 2017

IPSYCHIATRY
Psyc~iat~ic Special Care Units
Psychiatl)· Allocations: 2 North: 3 Psychiatrist+PA with 7-day Coverage(RFX1.7)
... ·2 South/Southeast: 2 Psychiatrist with 5-day Coverage .2West:2Psychiatrists with 7 day coverage(RFX1.7) 2 E: 1 Psychiatrist Once a month coverage
Physician /patient ratio on acute units> 1:15 Physician /patient ratio on subacute units> 1:30 Divisions with P2Housing/OutPatient Psychiatl)' Allocations:

Total

_929 daily av~rage population in Min /Med Security Divisions ( II,IV,VI) 500 dailv.~vef?ge ~eta_inees in Maximum security Divisions X an_d IX 175 daily average detainees in SMU {Division IV,VI,IX,X)are absorbed into P2

Apr-17

Residential Treatment Unit
·Psychiatry Allocations: Absorbs SMU P3 and P2 Populations( daily average 18) Absorbes l_n_ten:;ive Management Unit (average daily census 6) Mal~ and Female{average daily population is 400 P3 and 190 P2)* Total N9TE:*RTU P2 population is concentrated on the 2nd,3rd and 5th floors and is absorbed by Psychiatry staffing Physician/Patient ratio 1:147

,RCDC · Psychiatry.AIIocations
Monday, Tuesday, Wednesday,Thursday, Friday**

Total

Grand Total FTE (Psychiatrists, Psychiatric PA, Consulting/Locums)
NOTE:* RCDC has shortened shifts- Shours NOTE:** 2 Psychiatrists {1 for Male RCDC, 1 for Female RCDC) 1F}E onsite hours =52 weeks=2080hours per year _Chief~sychiatrist provides no direct service hours Psychiatrists do not.Pe.~orm administartive duties
Staffmg Summary for Psychiatry:

--

o The main task remains attracting full time Correctional Psychia1rists through assertive national search and advertisement campaigns.

Case: 1:10-cv-02946 Document #: 356 Filed: 05/02/17 Page 62 of 89 PageID #:5476
Appendix IV The Agreed Order Status Update Page 35 of 59
o One Psychiatrist transitioned from a Part time to Full time position. Another Psychiatrist was hired.
o 2 part-time Psychiatrists vacancies now exist (one Psychiatrist resigned and one converted to the Full Time Status). The majority of part-time (Account 133) Psychiatrists are committed to working between 8 and 20 direct service hours. There is one filled position of a Consulting Psychiatrist. The rate of compensation for this position has been made sufficiently attractive.
o Recruitment in progress: One FT Candidate has been credentialed and has estimated starting date in August (finishing Forensic Fellowship); two other FT candidates are in Credentialing; one Candidate in Credentialing for the Consulting Position
o Telepsychiatry has been expanded on the compound and, in addition to flex time arrangements, continues to be an important recruitment and retention instrument. Telepsychiatry clinics function successfully in RCDC, Divisions VI, D2D, and X. The rate limiting step in the expansion ofTelepsychiatry remains the availability of Telepsychiatry Clinic Attendants. Presently two Locums Attendants are working on campus.
o One additional Physician Assistant has been hired. Now 2 Physician Assistants are employed. Two MH PA's exceed Departmental expectations in terms of productivity and quality. As a point of reference, PCC employs 18 PA's and has zero vacancy rate for PA's. As a future direction, Chief of Psychiatry collaborates with Cermak CCO to augment current staffing with Pharm. D's and potentially expand the lines of services where PA's are deployed.
o A position of the Associate Director of Correctional Psychiatry was posted in February 2017
o Cermak has contracts with 4 (three) staffing agencies to provide Locum Tenens Psychiatrists: Medical Doctor Associates (MDA), Maxim Physicians Resources, Columbus Organization, and Regroup. All Vendors' contracts have Amendments for Telepsychiatry. Dr. Garb, furnished by Columbus, is deployed on site at Cermak in Division X. Dr. Pandit (Maxim) provides direct service hours in Division X as a Telepsychiatrist. The contracts for the three locum tenens agencies have been extended into 2017. Based on present clinical needs and recruitment yield, Cermak Mental Health Department projects that we will continue to need staffing assistance. Some of the Locums Psychiatrists who are currently in the credentialing process did not complete it. One Locums Provider decided not to pursue this position after the first two weeks of Orientation. Another Vendor (ReGroup) was added to the previously active Vendors. They specifically contracted to provide Telepsychiatrists and not on site personnel. Two

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AppendixN The Agreed Order Status Update Page 36 of 59

Locums Medical Assistants perform as Telepsychiatry Clinic Attenddants while CCHS is exploring how to create en employed position of the Medical Assistant.

o Ongoing current advertisement efforts by CCHHS involved postings in industry publications, including the AAPL quarterly letter, communication with the local feeder schools, and participation in local Psychiatry Fairs (October 2016).

o Additional staffhired in the CCHHS's Credentialing office will provide for increased support to engage applicants and expedite processing.

o "Advanced Clinical Process (ACP)" at Cermak has been in place since November 2015. The Advanced Clinical Process was created to assist Cermak in filling hard to fill credentialed positions. The ACP process has helped enhance the recruitment process by allowing for the participation of departments to solicit candidates to submit resumes I CVOs to a centralized mailbox, which allows for the expedited review and determination of candidates meeting minimum requirements. Due to success of this pilot, the ACP process is now implemented CCHHS wide.

o As an important recruitment tool Cermak Psychiatry continues to support student and Psychiatry residents' rotations/training on site from nearby medical schools (Rush+ UIC's).

RTU staflmg.

RTU 5th floor females

RTU 4'h floor(+ 2nd and 3nl floors)

Psychiatrist

1.0

3.0

Psychologist/Unit

1.0

1.0

Director Social workers

I

I

1.5+ 1.0 Expressive

1.5+1.0 Expressive

I

II

therapist

I

therapist

Mental Health

3 MHS III in am

3 MHS III + 3 MHS

Specialists (cover

2 MHS III+ 2 MHS II

IIonAM

RTU 5th floor and

mpm

4 MHS III's on PM

Div. 4 for female services)

Population as of

P3 87 P2 41 ( 128)

I

3/31/2017

I

P3 286 P2 107 (393)

Staffing Levels vs Practice Patterns discussion: Information obtained during previous visits suggested that the amount of time allotted to initial psychiatric examinations was insufficient to conduct thorough initial evaluations, conduct medical records review, and enter documentation

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AppendixN The Agreed Order Status Update Page37of59
in EMR. To address the above concerns a number of measures were developed.
• A scheduling Pilot in Division VI started in Division VI. It allots 40 minutes for an Initial Assessment and 20 minutes for follow up sessions. CQI will be performed to assess the results and whether or not the above metrics will be positively affected by having increased time allotments.
• The Access to Care Collaborative DOC/Cennak Pilot is under way in Division IX. It automated communications related to patient movement, likely to increase movement to clinic efficiency, and flush out if detainees are brought to clinics at uneven intervals, thus, increasing demands on Providers at some times and making them idle during extended periods of time, if most of the patients are brought to the clinics before their closure. Patient movement to clinics is, at times, impeded in high security and special management areas, and those factors will be examined further through CQI studies.
.• Clinical Performance and Enhancement Peer Review Process was developed by the Chief of Psychiatry and the CQI study allowed to identify some outliers in terms of their adherence to safe practices. The results of the secondary analysis indicated that Providers who did not adhere to the standards of evaluation and documentation in many cases did have sufficient time to meet expectations and further in training and individual supervision will be used as corrective interventions. Relevant CQI study is available in the PDF Appendix.
• Following extensive chart reviews, JSH IT assisted in creating the following efficiencies withEMR:
a. Mandatory Fields were added to CHS Mental Health Notes designed for Initial Evaluation. They included history of present illness, prior psychiatric history, family history, psychosocial/legal history, and Brief Psychiatric Review of Systems. It will be impossible to close out notes without charting in those sections. The attestation functionality by a Physician pennitting them to log how much time was expanded on direct patient face to face care. Further studies will be conducted using functionality to assess Providers' self-report against what Cemer registers ( EMR is able to pull the data on how much time notes were opened during each patient contact).
b. A Note was modified to replace existing Psychiatry Follow up EMR note to further increase the efficiency of documentation. That notes contains the attestation functionality by a Physician permitting them to log how much time was expanded on direct patient face to face care. It is understood that in the correctional milieu the amount of waiting time can significantly affect clinical productivity and, yet, the System does not allow Providers across CCHHS to document waiting time based on prior best practices and precedents.
c. As elsewhere discussed, a new Master Treatment Plan template was introduced for P2 populations. The results of chart audit are discussed in the section dedicated to treatment plans.

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Appendix IV The Agreed Order Status Update Page 38 of 59
• Frequency of contact with Providers study was undertaken in all the Levels of Care to address concerns that patients are dealing with unreasonably high waiting times. The results ofthis CQI study are available in the PDF Appendix.
• Discharge planning issues, especially as it relates to Psychiatry discharges in high turnover minimum security areas, have been discussed with DOC. It was decided that post discharge follow up issues had to be addressed in a centralized fashion in order to avoid confusion inherent in the scenarios when different instructions are given by multiple parties. CCDOC Department of Inmate Services, with the input from Cermak, developed a comprehensive Inmate's handbook where post discharge and follow up issues will be addressed in the Handbook's second addition in 4/2017. The audio broadcast containing Handbook information overview in its entirety is received by every living Unit during Sunday and Wednesday broadcasts. Living Units are encouraged to broadcast this information as frequently as they want to. Additionally, discharge issues and post-discharge linkage are extensively discussed by MSW with patients. Relevant CQI study for post-discharge linkage available in the PDF Appendix.
Summary for Psychology: There is a total of I0.0 FTE psychologist positions (excluding the Chief Psychologist position) with a current vacancy rate of30% (3 FTE). Cermak has lost several candidates in later stages of their hiring process due to the fact that their internships were not APA approved. Efforts are made to vet candidates early on to identify candidates whose internships would disqualify them from receiving clinical privileges at Cermak. Furthermore, Cermak MH Leadership is working with the CCHHS Credentialing Committee to modify presently existing minimum job criteria from having APA certified predoctoral internship to the APPIC accredited training. The language and research were submitted to the Credentialing Committee. Resolution is pending. This step is designed to expand the pool of prospective candidates, while deferring to MH Leadership to vet deserving candidates and further strengthening the post-hiring Professional Evaluation Process.
For FY 2017, Cermak has submitted a request to fund 2 post-doctoral Psychology Fellows to work under the supervision of the Chief of Psychology, to provide diagnostic assessment, crisis intervention, intake evaluations, group and individual therapy, consultation with multidisciplinary treatment team, projective and objective psychological testing, security and civilian staff training, and supervision of practicum students.
There is a total of70 MHS Specialist Positions with a current vacancy rate of5.7 %. There are those who are presently enrolled in a Master's program and expected to be eventually licensed. They will be expected to complete their degree/licensure by specific, individualized dates (based on current status and anticipated licensure date).The ones who have matriculated Master's Programs and obtained licensure are being promoted into MHS III Positions. If these employees do not achieve licensure by their specified dates, their position will be eliminated. The first rounds of separations took place in July 2016. Presently, licensed staff (as they meet their educational and licensure requirements) is being promoted to fill positions vacated by the unlicensed staff.

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AppendixN The Agreed Order Status Update Page 39 of 59
At the start of the fiscal year Cermak received support for 14 new Mental Health Specialist III positions and 1 Activity Therapist. Most ofthe MH positions have been posted. Interviews are ongomg.
In November 2016, the Cermak MH department undertook a comprehensive review ofits staffing and staff productivity, including the average number ofhours of group treatment provided to detainees housed in P3/lntermediate housing units and the number of scheduled groups, clinics or other services cancelled due to a lack of staff. The review focused on services delivered by Mental Health Specialists. The department created a multifaceted approach to increase the number and quality of services, including strictly enforcing the time and attendance policy, requiring that staff provide at least two-weeks notice for all planned time off, increasing clinical supervision for staff whose productivity was low compared to other employees with comparable duties, imposing disciplinary action for employees found to misrepresent their productivity or who cancelled services inappropriately, establishing minimal critical staffing levels for all clinical areas and pursuing an agreement with the union representing the MH specialists to mandate overtime.
Beginning with February 2017, the department began to mandate OT for planned absences and, beginning in mid-March 2017, for staff call ins. Staff are required to provide a minimum of 2 hours' notice when they call off work.
When an employee calls off, MH leadership sends out a group email to all MH Specialists III staffrequesting volunteers to cover the post. If no volunteers are found and the post is considered critical, employees on the campus are mandated to cover the post.
There is a total of 6 Medical Social Workers Positions. 6 positions have been filled.
The mental health staff vacancy rate is 14.2%.
Positions of the Chief of Psychiatry, Chief Psychologist and Mental Health Director are filled.
April2017 Metzner assessment: The functional vacancy rate for the psychiatrists appears to be the lowest since the implementation of the Agreed Order. When allocated part-time and consulting psychiatrists' positions are translated in terms ofFTEs, and psychiatric physician's assistant FTE positions are included, Cermak has approved funding for about 20 FTE line staff psychiatric provider positions in contrast to the 15.0 FTE line psychiatric positions described in the staffing summary from 2014. It appears that 3.0 FTE psychiatrists will be hired by August 2017.
It is my recommendation that 1.0 FTE of the anticipated 3.0 FTE psychiatrist new hires be allocated to the RTU in order to cover any P2 imnate residing in the RTU as well as covering the IMU and RTU SMU. This would reduce the psychiatrist: P3 staffing ratios to a more acceptable level. Increasing the psychiatrists' allocations to the compound P2 population by 1.0 FTE

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Appendix IV The Agreed Order Status Update Page40 of 59
psychiatrist would decrease the psychiatrist: inmate patient ratio from 1:346 to 1:290. Adding 2.0 FTE psychiatrists would decrease the psychiatrist: inmate patient ratio to 1:246, which would be an acceptable staffing allocation.
QI studies indicated that psychiatrists were frequently assessing/evaluating caseload inmates (both P2 and P3) with a frequency greater than the minimum required intervals. P3 inmates reported that they were generally seen on a monthly basis by a psychiatrist.
A targeted random sampling of 13 CCDOC detainee charts was reviewed jointly with Dr. Kelner with parameters of those who received a "P2" assignment between November 2016 and February 2017. Findings of this chart review indicated overall the initial psychiatric evaluation was completed within 14 days of the screening; many of the initial evaluations were completed within seven days of referral. The quality of the psychiatric assessments varied. Focused clinical assessments predominated as opposed to comprehensive initial evaluations. Diagnostic assessments were generally adequate, though at times, prior diagnoses were continued without any clinical documentation supporting the diagnosis. The prescribed medications were congruent and appropriate to the listed condition. There were only a few cases in which limited indication was documented as to why a particular medication was prescribed. Few detainees were prescribed medications such as mood stabilizers that necessitated screening and follow up blood work. Of these, one had a Depakote level ordered in an appropriate time-frame, but no other lab work. A second had appropriate pre-screening and follow up labs.
Another 8 CCDOC detainee charts was reviewed jointly with Dr. Kelner with parameters of those who received a "P3" assignment between November 2016 and February 2017. Findings of these chart reviews indicated that the majority ofthe patients were seen in a timely manner, some seen within several hours of initial intake screening. Overall, the psychiatric assessments were thorough with appropriate diagnostic clarity with congruent treatment plans. The main problem area identified in chart review was with detainees assigned to the intermediate care "overflow" units. The initial psychiatric assessment tended to be delayed beyond the anticipated timeframe. In particular, one detainee with serious mental illness was not evaluated by a psychiatrist for five weeks after initial screening. However, this pattern of overflow detainees had already been identified by Cermak staff, and it has reportedly been rectified by assigning a psychiatrist to specifically cover the "overflow" unit, along with a printed list of each "P3" detainees in the units to review at staffing. Overall, the follow up psychiatric evaluations were performed in a timely manner based on clinical necessity with only a few exceptions. Only one detainee was prescribed medications while in intermediate care that mandated lab work, which was performed appropriately.
Follow up appointments for the P2 detainees were also generally appropriate, with a time frame of four to twelve weeks depending on clinical scenario. In one case, a detainee was prescribed three psychotropic medications, but he was lost to follow up upon transfer to different divisions. He did not receive a psychiatric follow up prior to discharge from the jail within the requested appointment timeframe.

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Recommendations: As above.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures def"ming the various levels of care and identifying the space, staffmg, and programming that are appropriate to each identified level of care.
Compliance Assessment: Substantial compliance (4/17)
Factual Findings:
April2017 Cermak Status Update
Please see Update in 59f.
April2017 Metzner assessment: See Update in 59f. The substantial compliance finding is based on the assumption that the recently allocated 14.0 FTE mental health specialists' positions will be filled in a reasonable period of time, and as well as the psychiatrists' and psychologists' vacanc1es.
Recommendations: Continue the aggressive recruiting and hiring process.
h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate.
Compliance Assessment: Substantial compliance (11/16)
Factual Findings:
April2017 Cermak Status Update
Cermak Male Acute, Subacute and Chronic Mental Health Unit Descriptions
The Cermak male psychiatric units are comprised of 60 beds distributed among 3 units- 2North (acute unit), 2South (subacute unit) and 2East (chronic unit). The purpose of the units is to provide extended observation, stabilization and structured/unstructured therapeutic activities. Services are provided by a multidisciplinary team, which includes psychology, psychiatry, mental health specialists, nursing, social workers, correctional rehabilitation workers and custody staff.

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Male detainees may be admitted to 2North, the 24-bed acute psychiatric unit, from intake, general population or other mental health nnits. Primary reasons for admission include an acute risk for harm to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for victimization in other living nnits. Detainees housed on 2North are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2North for a brief period of time before transitioning to a less restrictive setting.
The subacute mental health nnit, 2South, is a 26-bed unit for detainees that have demonstrated a decrease in the severity of psychiatric symptoms but continue to evidence symptoms that cannot safely and adequately be treated in a division with mental health services. Some detainees exhibit chronically severe symptoms that necessitate long term sheltered housing. They may be housed on 2South or 2East, a 12-bed unit that houses detainees that demonstrate severe negative symptoms of psychosis, chronically severe depression and/or significant cognitive delays.
2S/2SE concentrates the most recalcitrant and treatment refractory detainees with serious mental illness on the compound. In order to preserve a safe, sanitary, and therapeutic milieu in the area where adherence to hygiene and personal self-care is often a challenge for many of those detainees, Cermak MH, Environmental Services, and DOC staff collaborate in maintaining:
1. Cleaning schedule- twice a day (am and pm) including the weekends on both 2S and 2SE. The pm cleaning is for selected cells that need extra attention. Power washing frequency is to be determined. Supt. Hays is asked to provide staff to assist the cleaning of2S/2SE.
2. Additionally, DFM Plumbing foreman have been requested to have a plumber come to 2S/2SE every morning Monday through Friday.
3. DOC avoids, if possible, feeding detainees in their cells, when practicable, in order to minimize the resurgence of fruit flies' population.
4. "Humanitarian showers" on the 3-llPm shift are available as needed in close coordination between DOC, PCS, MHS, and Psychiatry. MH will submit the lists of detainees requiring hygiene to Supt. Hayes and Shift Commanders. MH will secure OT, ifneed be, to assist in coordinated preplanned hygiene.
5. Cleaning and environmental maintenance should not interfere with ongoing out of cell therapeutic programming.
CCDOC Update:
2NortW2SoutW2West/2East
The General Population detainees/patients receive time out of cell for a minimum of 8 hours per day, though most days exceed 10 hours of out of cell time. Problematic detainees that require time out of cell alone receive 2-3 hours out of cell each day depending on their behavior. These detainees receive out of cell time in an area separate from the general dayroom area. Units 2North, 2West and 2South have all been retrofitted to include a contained area for such

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problematic detainees to recreate outside of his/her room while dayroom activities continue for the larger population. Protective Custody detainees are encouraged to participate in programming for additional hours out of cell.
Cermak Detainee Hygiene
DOC, nursing, environmental services and mental health staff continue to be proactive with managing inmates with poor hygiene in Cermak. Once a humanitarian shower is requested, all staff work together to accomplish the task.
The Sheriff's Office worked collaboratively with the Illinois Department of Human Services to draft a bill that would reduce the amount of time it takes to transfer a detainee to a state forensic hospital after a finding that he/she is unfit to stand trial or not guilty by reason of insanity. As a result ofthe Sheriff's Office advocacy, the number of individuals awaiting transfer to DHS and the amount of time it takes to transfer has been greatly reduced thereby positively impacting the Cermak census.
Recreation: Detainees in Division 08 RTU have access to recreation on the patio and in the indoor and outdoor recreational spaces of other divisions. The detainees are offered access to recreation 3-5 times weekly. In the month of March, detainees housed on the 4th floor ofRTU were provided access to recreation an average of thirteen (13) times. Detainees housed on the 5th floor ofRTU were provided access to recreation an average of seventeen (17) times. The DOC has been working diligently with our County partners to winterize the RTU patios in 2017. The 4th and 5th floor patios are expected to be winterized by the Fall of2017.
Recreation is offered to Cermak 2nd floor detainees at least twice weekly in the 3rd floor recreational space. Detainees often refused to participate in off-tier recreation due to the lack of a television and instead elected to spend their recreation time in the dayroom of the living unit. The Cermak Superintendent recently secured a television for the recreation room. Additionally, the Cermak recreational space is equipped with a ping pong table, bag toss games and board games.
Cermak Female Acute and Chronic Mental Health Unit Description
The Cermak female acute and chronic mental health unit, 2West, is a 20-bed unit devoted to the psychiatric stabilization of detainees whose presentation warrant stabilization and/or extended observation. Detainees may be admitted to 2West from intake, general population or other mental health units. Primary reasons for admission include an acute risk for harm to self or others, acute psychosis, and an inability to care for self or marked decompensation that poses as a risk for victimization in other living units. Detainees housed on 2West are scheduled to see a psychiatrist 5-7 times per week. Detainees are typically housed on 2West for a brief period of time before transitioning to a less restrictive setting unless they present with symptoms that warrant chronic care services. Chronically mentally ill detainees that require continued housing

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on 2West demonstrate severe negative symptoms of psychosis, chronically severe depression and/or significant cognitive delays that cannot safely and adequately be treated in a division with mental health services.
According to the Interagency PSCU Policy, bed assignment is a collaborative task between DOC, Nursing, and Mental Health. Striving to maintain the integrity of ongoing out of cell structured therapeutic programming and recognizing the importance ofhaving dayroom available for therapeutic programming, Cermak supports using every appropriate space/accommodation for patients in need of single rooms, including, but not limited to:
• Temporarily holding 2N detainees on 2S and 2E. When there is a new admission(more unstable) to 2N in need of a single room, more stable 2N patients occupying a single room may be transferred to 2S and 2E on a temporary basis.
• Using existing single rooms on 2N (putting new detainees in need of single room in the rooms of established (stable) single room patients who are having their "hour" out).
• Using group rooms (when group room detainees are out for therapeutic and unstructured activities) to temporarily insert new admissions in.
• Temporarily keeping new detainees in other appropriate clinical/non clinical space on 2N (for instance, the long hallway and the small group room). DOC is requested to provide direct observation of these detainees if they are kept in clinical areas.
• Keeping new detainees who need a single room in the big dayroom will be used only as the last resort.
Providers, Unit Directors, and MHS will collaborate with DOC Supervisors and front line staff identifying accommodations designed to avoid any disruption in therapeutic programming.
Psychiatric coverage of the Psychiatric Special Care Units has been largely unchanged: 2N is covered by 3 Psychiatrists and 1 Psychiatric PA (Balawender. 2W covered by 2 Psychiatrist. 2S/2SE is covered by two Psychiatrists. 2E is covered by on Psychiatrists. All the Psychiatrists combine PSCU coverage with some divisional clinics. Section 59f. has detailed descriptions of Psychiatric allocations within the PSC Units. Please see PDF Appendix for QI related to frequency of contact of PSCU patients. Two Psychologists are dedicated to PSCU: one being a Unit Director for 2N/2W and the other for 2/2SE/2E.
2 North & 2 West Updates
2N (males) and 2W (females) are the Psychiatric Special Care Units within Cermak Health Services that provide psychiatric/mental health services to a population of acute, sub-acute, and chronic individuals. A psychiatrist meets with each patient within 24-hours of admission and then daily thereafter. Structured group programming is delivered daily to patients, which range from a "Rise and Shine" group focusing on hygiene/ADLs, to "Community Meeting/Unit Orientation," as well as more clinically focused groups such as "Grief/Loss Group" and "Community Reintegration." Patients on PSCU have access to a Mental Health Specialist III

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(licensed clinical staff) 24-hours a day, 7 days a week. Structured programming is delivered 7 days a week on both the 7-3 and 3-11 shifts.
Programming
Clinical groups take place both in the day room and in the small group room and generally engage patients in discussing topics such as Anger Management, Coping Skills, Patient Rights, Understanding Mental Illness, etc. Dayroom hours and structured programming are calculated most closely on the 2 North Unit. Through an interagency directive, both dayroom hours and programming hours have been increased on 2 North and 2 West.
Patients housed on the Special Care Units are seen by a Mental Health Specialist during rounds on each shift, and they have access to a licensed Mental Health Specialist 24 hours a day. Patients are engaged in the milieu (dayroom or interview room) or cell front if necessary for security or clinical reasons. Patients also have access to psychiatric services while housed on the Special Care Unit. They typically meet with a psychiatrist or physician's assistant up to daily while acute status or up to 5 days weekly if not.
A QI Project was initiated in May 2016 to ensure the accuracy ofthe reported dayroom hours. The QI entitled "Cermak Dayroom Hours" provides detailed information comparing the hours recorded by Mental Health staff with video footage of the dayrooms on 2N and 2W. The unit schedules aspire to provide 12 hours of open dayroom time every day where patients have access to care and are provided with 8 hours of structured programming. The interagency unit schedule is attached to the associate QI reports in the Appendix.
Group programming hours on 2N and 2W have remained consistently high over the last six months (Appendix). One factor that has contributed to increased consistency with regards to group programming hours is the decrease in group cancellations. The Mental Health department has worked with CCDOC leadership to decrease and/or prevent groups from being cancelled. This has increased access to care in terms ofpsychiatry, nursing, as well as group programming. Several approaches/solutions have been implemented to prevent dayroom closure including: 1) placing a newly admitted patient who requires a single cell in a room while group takes place and then after the dayroom hours return the patient to the dayroom, 2) placing the patient in the back hallway in a chair or ''boat" bed and provide security supervision, and 3) boarding more stable patients on other second floor units if there is available space.
There has also been an effort to increase programming offered in the small group room. This provides increased confidentiality and a more intimate setting for patients to engage in group therapy. A QI project was initiated in November and the results of that study will be presented in a separate CQI report entitled "CQI Small Group Room Programming." The results of this study suggest that there is still progress that needs to be made in terms of increasing the percentage of groups that take place in the small group rooms (Appendix).

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Treatment Planning An area of improvement that was identified during the last audit was treatment plan development, review, and update. Procedures have been initiated on both 2 North and 2 West to ensure that treatment plans are updated within the specified timeframes of our policies. The "Treatment Plan CQI" looks at treatment plans for P4's during the month of December. The overall compliance percentage of92% (up from 81% in October 2016) suggests that consistency has been maintained in terms ofthe development, review, and updating oftreatment plans. The quality and effectiveness of the treatment plan should be assessed moving forward. Outcome studies may help to better understand the impact our services have on our patients' mental health and wellbeing. The treatment plan audit and summary will be provided in a separate Appendix document analyzing treatment plans across the department.
Additional Activities In addition to providing assessment/treatment planning, milieu therapy, rounds, individual sessions, and group sessions, the mental health staff also meets daily in a "morning huddle" to discuss new admissions and any concerns or questions from the previous day(s). Staff will also regularly engage in multidisciplinary treatment .team meetings held twice a week on both units to discuss patient progress, update the patients' treatment plan, and address any other pertinent items/issues. The restraint and seclusion log for the previous week is reviewed twice weekly (am and pm shifts) at staffmg, and staff is given the opportunity to discuss any issues or questions they have with the process ofutilizing therapeutic restraint/seclusion. Multidisciplinary Treatment Team (MDT) meetings are scheduled regularly and invited parties include psychiatrists, psychologists, physician's assistants, mental health specialists, nurses, and correctional officers.
With regards to the milieu and therapeutic environment on the psychiatric special care units, staff work towards developing rapport with each patient and providing a sense ofphysical and emotional safety. This is especially the case on 2 West (females), where staff provides a more trauma-informed approach to working with patients. Staff encourages patient compliance with treatment while also respecting patients' rights. Mental health staff spends time describing patient rights with regards to medical/mental health treatments (i.e. right to refuse medications). The incentive program is utilized on 2 West to encourage patients to participate in healthpromoting activities, such as hygiene, group therapy, and medication compliance. Mental health staff tallies points and provides incentives for patients who engage in these activities. Mental health staff will modifY the incentive program for patients with special circumstances (such as out alone/house alone status) to make it possible for all patients to participate in the program. An area that has been improving is cooperation/collaboration across disciplines. This has traditionally been a challenge, but has been moving in a positive direction. Mental health specialists are more likely to communicate/collaborate with medical, nursing, and the officers. This collaboration can be challenging at times due to discrepancies between professional perspectives and opinions, but has been improving. The increased collaboration amongst leadership may be driving this improvement (i.e. regular interagency management meeting and

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multidisciplinary staffing). We will continue to hold multidisciplinary clinical staffings to ensure that all disciplines are represented and that all varying perspectives are taken into account.
Areas for Improvement The key areas identified for improvement during the last reporting period (October 2016) were:
1. Monitor dayroom closures more closely and develop interagency procedures to prevent dayroom closures - There has been a decrease in dayroom closures on the past six months (see programming statistics).
2. Increase small group room programming by scheduling one small group per clinician per week- This continues to be an area for improvement according to the Small Group Programming CQI. Staff will be scheduled to provide one at least small group per week.
3. Continue to encourage CCDOC attendance/participation at clinical staffings- CCDOC staff has been more present at clinical staffings/MDT. Mental health patient care is also a standing item that is discussed at the weekly interagency management meeting.
4. Continue to monitor compliance with treatment plan policy- There has been continued improvement in this area and procedures will continue to be implemented and reviewed to ensure that treatment plans are reviewed in a timely manner (in accordance with policy) and that the patient is informed ofthe plan and/or participated in developing the plan.
Improvement areas for this reporting period:
1. Increase small group room programming by mandating that each mental health specialist assigned to each special care unit (2N and 2W) provide one small group per week.
2. Continue to develop procedures to ensure patients are informed of their treatment plan and that the plans are updated within the specified timeframes.
3. Continue to regularly evaluate group quality through conducting random structured evaluations and providing feedback to mental health staff.
2 South/east & 2 East Updates:
The 2 South offers up to eight hours of structured group programming and unstructured dayroom activity per day, seven days per week. Because of a staffing shortage, 2 East currently offers dayshift group programming only; additional staff are in the process of being hired currently for evening shift. 2 Southeast does not currently offer separate programming with the exception of expressive art therapy. Patients who are able to participate in group programming and milieu activities join these events on 2 South. 2 Southeast patients who are not able to tolerate the stimulation of group activity are given individual time out alone or in twos or threes. Some patients require restraint when in the dayroom to ensure safety of others. These patients are brought out only with other individually restrained patients.
Programming includes daily 'Rise and Shine' group, a morning hygiene group, Community Meeting, Medication Management Group, Coping Skills, Anger Management, Current Events,

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Art Therapy, and Community Reintegration, Chair Yoga, and other topics. Daily schednling of programming follows the same timeframe as that of2 North and 2 West. As on 2 West, all three male nnits utilize the incentive program to promote to participation in hygiene, group programming, and compliance with medications.
Developments in the Last 6 Months
1. Separating 2 Southeast from 2 South has helped promote a more therapeutic milieu on both nnits. More aggressive and disruptive patients have been better managed in the smaller, less stimnlating environment of2 Southeast. In addition, modifications have been made to the physical plant to promote safety. Aggressive, highly impulsive patients can spend more time out-of-cell with the installation of secured television sets and secured 'watching stations' in the dayroom. 2 South patients are able to participate in programming with reduced risk of disruptive, aggressive, or predatory behavior by more severely impaired, treatment-refusing individuals.
2. There has been a strong effort by Psychiatry to increase the number of cases petitioned for involuntary court-ordered medications.
3. Recent hiring of additional psychiatrists have increased coverage by attendings on these units, promoting improved quality of care. In addition, recent approval of additional Mental Health Specialist positions is expected to provide coverage on 2 East for evening shift and reduce the need to 'pnll' staff to provide needed coverage when staff members call in sick.
4. Recent enhancements to the nnits include the trial use of tamper and ligature resistant sprillkler heads in the patient rooms. A nagging design flaw in Cermak has been the use of exposed sprinkler heads, which are relatively easy to break, causing major flooding. Several times a year, the nnits become flooded as a resnlt of patient tampering, causing water to leak through the ceiling and damage administrative offices on the first floor. It is anticipated that all rooms will be refitted with these new and safer sprinkler heads over time.
5. In conjunction with Ms. Lonna Speer, inventor of the safety smock, our staff has been working with her company, Ferguson Safety Products, to design a safety jumpsuit which looks 'less like a dress', and is more dignified, durable, and tamper resistant. We have used several prototypes with our patients to beneficial effect. In addition, beds on the nnits are being replaced by newer and safer 'moduform' beds.
6. With these improvements in staffing and the physical milieu, there have been increases in programming hours, staff and patient safety, and successful management of the most severely mentally ill patients in the CCDOC system. This has meant that patients can be maintained in Cermak with less movement off-tier due to extreme disruptive and aggressive behavior. In conjunction with increasing the number ofpatients petitioned for

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involuntary conrt ordered medications, it is anticipated that we will be more successful in managing and stabilizing our most challenging patients.
Medical Social Work: Discharge Planning
The Cermak PSCU is staffed with 2 Medical Social Workers who maintain regular contact with detainees diagnosed with serious mental illness to coordinate post-release treatment services in the community. Due to the severity of their mental illness, all detainees released to the community from PSCU must be assessed by a Qualified Mental Health Professional prior to discharge to determine the need for hospitalization. If community hospitalization is not warranted based on the clinical assessment, the Medical Social Worker can assist the detainee with referrals to community agencies for continued treatment and shelters for housing. The Medical Social Worker can also arrange for the detainee to be given a prescription for discharge medications. Please refer to Appendix for QI related to discharge planning at all levels of care.
One new and exciting resource available to the MSW staff is the CCHHS Community Triage Center (CTC). The CCHHS Community Triage Center is one tactic we are implementing to address the overwhelming lack of behavioral health care services across our region. Patients released within short time frames or prior to completion of a comprehensive discharge plan can be referred to the CTC for a "soft hand-off' after release. The CTC staff can serve as a touch point in the community for a detainee upon release to make sure he or she can continue keep their behavioral health condition controlled outside of a the jail environment. The CTC will be additionally useful as a case management resources when Cermak medical social workers arrange community linkage to discharged patients; however the agencies are often closed for the day by the time the patients are discharged from the jail. The CTC will serve as an identified location that community agencies can connect with the patient's the following day.
CCHHS looked at the locations of the patients brought to its emergency departments with behavioral health conditions, as well as the home zip code of detainees with behavioral health conditions at the Cook County Jail to determine which area in the County was the most in need of community-based behavioral health services. Based on the data, the Roseland community was identified as one of the most underserved areas in this respect, which is why it was chosen as the location of CCHHS' first CTC.
The Medical Social Workers also continue to be an integral part ofthe response to calls received by the Sheriffs Care Line. All information related to mental health issues continues to be forwarded to the identified medical social workers for follow up and/or delegation to divisional social workers if indicated. Since the last visit, our social work staff has addressed 35 calls/referrals. Of those referrals, (66%) had already been identified, evaluated, placed on the MH caseload and were receiving treatment. (9%) ofthe referrals yielded new additions to the MH caseload or yielded information that Cermak providers did not yet have access to, and the remaining (25%) referrals were determined to not be in need of continued follow up from the MH department. This collaborative community outreach effort has resulted in increased access

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to collateral information and opportunity for improved care and clarification of needs.

Detainees meeting criteria for involuntary admission by petition and certificate are transported to one of two area hospitals (Mt. Sinai and St. Anthony) upon release from Cermak by the court system. All detainees with P4 alert are evaluated at the moment of court release, and those anticipated to meet criteria for involuntary admission in the community are also 'flagged' ahead of time in EMR to ensure that their need for continued inpatient treatment is not overlooked if they are released in the overnight hours. There has been no indication of 'missed' evaluations at discharge recently, and the program continues to be efficient.

INVOLUNTARYHOSPITALIZATION BYPETITION

& CERTIFICATE UPON RELEASE 2014-17

YEAR Q1

Q2

Q3

Q4 TOTAL

2017

16

16

2016

10

13

11

15

49

2015

12

15

5

13

45

2014

12

I

I

131 111 11

47

Detainees meeting criteria for the administration ofinvoluntary medications (non -emergency basis) continue to be evaluated for filing of the Petition. Some patients refuse to accept psychotropic medications, sometimes even in cases when their safety and survival depends on their receiving treatment. In those cases, judges are petitioned to authorize involuntary treatment. Typically our petitions for the administration of involuntary treatments are heard by the judges at the Circuit Court of Cook County. Cermak's petitions for the involuntary administration of psychotropic medications undergo vigorous judicial review and are not afforded the administrative review process. While preparing these petitions requires many hours ofmedical research and clinical data analysis, this painstaking process was made even more difficult by the fact that Psychiatric Providers have to travel to the Daley Center for the hearings. Following a Curcuit Court Resolution permitting the use ofTeleequipment to conduct court hearings from remote sites, Circuit Court Judges began conducting hearing remotely, allowing respondents, lawyers, witnesses, and Psychiatrists to be present at the Leighton Center, thus greatly reducing Cermak's travel and time expenditures. Additionally, in order to improve efficiency and continuity of care between Department of Mental Health Facilities where detainees are remanded for the restoration of fitness, a reciprocal process has been developed, allowing for the modifications of Court Orders for Involuntary Medications ( non-emergency basis) to other counties when detainees leave CCDOC campus for DMH facilities and, conversely, detainees returning from DMH following the restoration of fitness have their court orders for involuntary medications "domesticated" to Cook County. The CCHHS Office of General Counsel has been greatly responsive to Cermak's needs and coordinated various aspects of the said process. The table before summarizes some of the recent trends.

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Involuntary medications by court order( nonemergency basis) FILED/ORDERED [QUARTERLY 2014-17]

I YEAR I

2017

I

I

2016

Q1
I
6/31 312

Q2 I Q3 111 3/3

Q4 I TOTAL I

6/3

I

I

716 14112

2015

311

111

111 I

212

715

2014

1111 2111 111

2/21 6/5 I

Of 6 the orders sought, during 2017, 3 were granted, 1 was mooted by inmate discharge, 1 was denied, and 1 is still pending.

Cermak periodically updates CCDOC Leadership on complex management cases. CCDOC Leadership discusses these cases with ASA and the Office of PD Leadership trying to establish priorities in streamlining cases and coordination between multiple parties. Cermak PCC and MH files petitions for Guardianship, when needed. CCHHS Office of general Counsel assists in gathering information and setting up hearings.

CCSO facilitated sessions of Crisis Intervention Training (CIT) training for Cermak clinical staff and custody staff. Staff selected to attend reported finding the training extremely useful. There have been 4 full40 hour classes and 1 one day training. Cermak's involvement is as follows:

13 unique staff completed the 1 day training (3 ofthose individuals are no longer with us). 34 unique staff completed the full40 hour training (1 of those individuals is no longer with us).

April2017 Metzner assessment: The significant improvements in the therapeutic milieu noted during the previous site assessment have been maintained as has the numbers ofhours of structured out of cell therapeutic activities being offered to detainees in the PSCU.

During the afternoon of April2 12, 2017 I observed a treatment planning meeting during the afternoon shift, which was attended by all the appropriate staff with very good multidisciplinary input. The psychiatric staffing allocations within the PSCU are very appropriate. Clinical staff observed were very competent in performing their tasks.

I also attended morning huddles foe Units 2W and 2N during the morning of Aprill3, 2017 and treatment team meetings for units 2N and 2S during the same day, which were all very well run.

i.

Cermak shall provide the designated CCDOC official responsible for inmate

disciplinary hearings with the mental health caseload roster listing the

inmates currently receiving mental health care. (included in this appendix for

formatting purposes only)

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Assessment: Substantial compliance (since June 2012)
j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate's serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate's mental health status.
Assessment: Substantial compliance continues (since October 2012). (included in this appendix for formatting purposes only)
Factual Findings:
April2017 Metzner assessment: Substantial compliance continues
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak's assessment.
I. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional.

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Appendix IV The Agreed Order Status Update Page 53 of 59
Compliance Assessment: Substantial compliance (11/15)
Factual Findings:
April2017 Cermak Status Update
Mental Health Department continues to provide 24 hour SMU screening for this cohort of detainees reentering restrictive settings. Mental health staff continues to conduct rounds on restrictive housing units at minimum weekly (in addition to the rounds conducted by Nursing/PCS). Please refer to 59 d. updates for discussion. Please see PDF Appendix for SMU Screening Compliance data.
April2017 Metzner assessment: Substantial compliance continues
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts au in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of au inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
Compliance Assessment: Substantial compliance (4/16)
Factual Findings:
April2017 Cermak Status Update
A restraint audit completed by the Cermak nurse manager, Madonna Mikaitis, R.N. can be found in the PDF Appendix.
Notifications to Facility Director/Chief of Psychiatry are issued via a new process whereby the System generates an automatic notification when a Nurse completes charting for FLR deployment and subsequent face to face contacts during the time when FLR's are deployed. The notifications are sent out to arrive to the recipients' Cerner in box and accompanied with emails. These notifications prompt to conduct chart review when FLR were deployed at least once over the past 24 hours (in keeping with Cermak Policy and pursuant to the IL Mental Health and Developmental Disabilities Code). EMR created a pool of recipients of the said notification, thus, allowing the Chief of Psychiatry to delegate the task of chart review.
Cermak Policy I-01 Restraint and Seclusion reflects that when issuing restraining orders for

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Appendix IV The Agreed Order Status Update Page 54 of 59

special populations (i.e. pregnant females, morbidly obsess with BMI> 40, BMI.35 with comorbidity, complex individual behavioral management treatment plans), patients will be evaluated and treated on a case by case basis.
April 2017 Metzner assessment: Substantial compliance continues.
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
Compliance Assessment: partial compliance
Factual Findings:
April2017 Cermak Status Update
There has been minimal change in the response to or compliance with timeliness in responding to HSRF since the last site visit, as the data has remained relatively unchanged. At this point we hypothesize that the reasons are multifactorial. Staffing has recently increased, however, newer staff have been in orientation and/or recently starting full assignments, so have not greatly impacted productivity. The access to care work group and pilot project in Division 9 is expected to uncover and assist the operational team in identifying solutions for contributing factors. Following significant increase in compliance and timeliness with response, we will look at the quality of the responses. What is encouraging is that more than 80% of the patients are seen for services despite not being as timely as we would like at this time. Please see Excel Appendix.

OCTOBER 2016 NOVEMBER 2016 DECEMBER 2016 JANUARY 2017 FEBRUARY 2017

COMPLIANCE

Patients Seen

92%

89%

90",1;

83%

83%

TIMELINESS Patients Seen on Time

49%

38%

51%

53%

52%

QUALITY CLINIC

April2017 Metzner assessment: My April2016 assessment included the following:

QI data documents issues in meeting timelines for responses to routine mental health referrals related to the current policy and procedure that requires a face to face triage for routine referrals within 72 hours and periodic delays in receiving the referral from nursing staff in a timely manner. I discussed with staff potential revisions to the pertinent policy and procedure that will significantly decrease the lack of compliance. In addition, the process involved with the sending of the

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AppendixN The Agreed Order Status Update Page 55 of 59
mental health referrals from the nursing staff to mental health services needs to be improved.
Specifically, it remains my recommendation that timeframes for HSRFs specific to mental health services that have been triaged as routine referrals be changed to and appropriate clinical mental health response to 10 business days.
Recommendations: As above.
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate's psychotropic medications are clinically justified and documented in the inmate's medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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.
Compliance Assessment: Substantial compliance (4/17)
Factual Findings:
April2017 Cermak Status Update
Periodic monitoring of blood levels of Lithium and Depakote is important for the safe administration of the said medications. It is suggested that blood levels are checked at least every 6 months, even if a patient remains asymptomatic and the dosage remains unchanged. A new Cemer alert was created. The logic now exists in EMR and, when Providers (both Medical and Psychiatric) try to order and, more importantly, reorder Lithium, Divalproex, and Atypical Formulary Antipsychotics, a new rule fires. If no Li and VPA levels have been ordered over the past 6 months, it prompts to order Li, VPA, and Lipid levels. In addition, the new rule will automatically fire with the tests for Non-fasting Lipids, Hb AI C, and weight measurement, if the said tests have not been performed over the past 6 months. As demonstrated by the chart, the frequency of medication monitoring has reached levels well above 90%.
Critical Medications Missing Alert has been built in Cemer. A list of patients who have missed 2 or more critical meds in the last 7 days is generated (including Clozapine and Decanoate formulations). This report is going to trigger a review by Providers. Additionally, Nurses need to report refusal of three or more doses to the provider and should do an eMERS. There needs to be a note entered into Cerner since many times patients have reported never being offered their

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Appendix IV The Agreed Order Status Update Page 56 of 59

medications when they have in fact refused.

The use of Diphenhydramine at Cermak reflects concerns about safety. In Psychiatry Clinics its primary use is limited to treating extrapyramidal side effects of neuroleptic medications and alleviating secondary insomnia caused by SSRI induction. However, Providers, at times, expand its use to the treatment of idiopathic insomnia, in the absence of any other psychiatric conditions, including adjustment reactions. Diphenhydramine capsules have been implicated in numerous overdoses on campus and have become something that is hoarded and sold on the black-market. Cermak Psychiatry Leadership advised Psychiatrists to avoid using this medications in cases of idiopathic insomnia when sleep hygiene should have been a better therapeutic response to patients complaining of inability to sleep. Detainees who overdosed on Benadryl, as in any other relevant situation, have the Medication Hoarding Alert input in Cerner and require a clearance with Chief of Psychiatry should a Provider decide to re-challenge them with the said medication. CQI study (mentioned in 59e) revealed an outlying cluster ofBenadryl prescriptions in Division X. Training with Providers was completed. Other measures are being introduced to limit Benadryl's availability: dispensation ofliquid Diphenhydramine and limiting one time prescription to 2 weeks' worth of the medicine followed by the Sleep Hygiene training.

Lithium (as of 3/22/2017)

#of Lab # of Med Order(person) Order

Ratio

21

21 100.00%

Divalproex Sodium/ Va1proic Acid (as of 3/22/2017)
Risperidone/ Ziprasddone/ 01anzapine (as of 3/28/2017)

138

127 92.03%

454

425 93.61%

Neuroleptic polypharmacy reflective of providers' practice has been studied. Polypharmacy rates are below of what is expected in the community setting. Please refer to Polypharmacy in Severe Mental illness QI in the APPENDIX.
April2017 Metzner assessment: See above update. Compliance has been achieved.
E. SUICIDE PREVENTION MEASURES
62. Suicide Precautions

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Appendix IV The Agreed Order Status Update Page 57 of 59
a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.
c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.
d. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:
April2017 Cermak Status Update
The Chief Psychologist worked with the IT team to ensure that the 'Serious Suicide Attempt History' alert in Cemer remains active across encounters. As such, the alert now automatically reactivates in the medical record with every admission.
See PDF Appendix for Suicide Detection and Prevention QI Report 2016 and Qtr. 1 2017
April2017 Metzner assessment: Substantial compliance continues.
65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:

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AppendixN The Agreed Order Status Update Page 58 of 59
April2017 Cermak Status Update
Please refer to QI reports referenced in provision #62.
April2017 Metzner assessment: Substantial compliance continues.
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
Compliance Assessment: Substantial compliance (11115)
Factual Findings:
April2017 Cermak Status Update
Several additional QI projects have been undertaken since the last site visit that can found in the PDF Appendix.
Mental Health Group Satisfaction Surveys Mental Health Group Programming Quality Mental Health Grievances 'Top 29' Staff Assailants in 9/10 & SMI Status
April2017 Metzner assessment: As has become the usual practice, the pre-site information packet, which included the QI appendix, was well done and extremely helpful. The QI studies were methodologically sound, well written and very relevant. Substantial compliance continues.
Nneka Jones, Psy.D. provided me with an overview of the CCDOC dashboard, which was part of a very impressive management information system. It is recommended that mental health services consult with Dr. Jones in the context of being able to use the dashboard for certain

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AppendixN The Agreed Order Status Update Page 59 of 59
mental health services QI projects.

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USA v Cook County, et al. Page9 of9
AppendixV

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AppendixV Re: Document requests Page 1 of2
Please have the following information available in hard copy at the time of the site visit, and sent to me one week prior to the site visit in electronic form (but not in PDF) unless indicated otherwise. Each piece of information should cover the period since the last site visit.
Note: If any of the requests are too burdensome to produce, please contact me before attempting to produce such information.
Appendix I Agreed Order 5/13/10 MH provisions revised
Using the word version of Appendix N in my last submitted report, after each of the "recommendations" section add the following section: [date of site visit] Cermak status update: and complete a narrative with proof of practice as available. This document request is the most crucial document. Please do not delete my April 2017 findings or recommendations exceptfor provisions that have beenfound in substantial compliancefor at least 18 months.
Some of the following requests may be in the above document and only need to be referenced-it does not have to be provided twice.
Mental Health System
1. The mental health system organization chart (with both position and name ofperson filling the position and his/her credentials- e.g., degree).
2. Any new policies and procedures relevant to mental health services.
3. Any new program descriptions of the current mental health system.
4. Any other reports (i.e., internal or external reviews) relevant to the mental health system at CCDOC.
Institutional Program Status
I. Narrative summary of program status
Staffing
I. List authorized mental health staff positions by discipline (psychiatrists, psychologists, social workers, nursing staff, clerical staff, etc.) and by program/area (intake, crisis stabilization, mental health housing units, etc.). For each position, indicate the person's name, professional degree, start date, and percent ofFTE ifnot full-time. If the position is vacant, provide the date it became vacant. For any staffon leave, indicate the date the leave began.

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AppendixV Re: Document requests Page 2 of2
2. List any newly allocated mental health positions and the dates they were established.
Census/Mental Health Roster
1. The total number of inmates in the jail, total number in segregation units, total number of mental health caseload inmates, and total number of inmates in each program area (crisis observation, mental health housing, general population, etc.).
2. Statistical information pertinent to the reception center screening of inmates (i.e., number of persons on a daily, weekly, or monthly basis for the past six months, percentage of inmates who have positive screens from a mental health perspective, percentage of inmates with positive screens who enter the continuum of mental health services, percentage of all newly admitted inmates who enter the continuum ofmental health services).
Quality Improvement
1. A copy of each relevant QA/QI audit conducted, preferably in electronic forms. For each audit provided, a description of:
a. Statement of the issue being studied b. Methodologyused c. Results d. Assessment of results e. Plan of action based on the assessment
Suicide Prevention
1. For any completed suicide, a copy of the mortality and review report.
Additional Items
1. Schedule of group therapies/structured out of cell therapeutic activities offered to inmates in the mental health housing units.*
2. Logs showing the use of restraints and seclusion, including the dates and times the orders were initiated, renewed, and discontinued, and the timing of nursing checks conducted.*
*Does not need to be sent in advance ofsite visit

 
 Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 1 of 56 PageID #:5604

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS, EASTERN DIVISION

UNITED STATES OF AMERICA,
Plaintiff,
v.
COOK COUNTY, ILLINOIS; THOMAS DART, COOK COUNTY SHERIFF (in his official capacity); TONI PRECKWINKLE, COOK COUNTY BOARD PRESIDENT (in her official capacity); COOK COUNTY BOARD OF COMMISSIONERS (in their official capacity),
Defendants,

No. 10-cv-2946 Honorable Judge Virginia Kendall

Monitor Esmaeil Porsa, MD Report No. 15

Esmaeil Porsa, MD, MPH, CCHP Associate Chief Medical Officer Senior Vice President Professional and Academic Affairs 5201 Harry Hines Boulevard Dallas, Texas 75235-7746 esmaeil.porsa@phhs.org

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Cook County Jail Fifteenth Monitoring Report
by Esmaeil Porsa, MD, MBA, MPH, CCHP-P, CCHP-A
November 2017

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EXECUTIVE SUMMARY During the week of November 13, 2017, the Medical Monitoring Team (Monitoring
Team) visited Cook County Jail. The team included: Esmaeil Porsa, MD, MBA, MPH, CCHP-P, CCHP-A, Muthusamy Anandkumar, MD, MBA, Madeleine LaMarre FNP-BC, and Linda Pansulla, RN, MBA, CCHP. The Monitoring Team visited many of the Cook County Jail medical facilities and housing units. We also interviewed various Cermak and Cook County Department of Corrections (CCDOC) leadership and front line staff as well as Cook County Jail inmates. We extend our most sincere thanks to all the Cermak and CCDOC leadership and staff for their hospitality and generosity with their time and resources. We additionally thank Cermak and CCDOC leadership and staff for their openness to the Monitoring Team suggestions and our critical appraisal of Cermak’s processes and activities over the past six months. Cook County Jail Cermak and CCDOC personnel were completely cooperative and helpful in this monitoring visit. The Monitoring Team enjoyed full and unhindered access to all areas and staff.
Our last visit in April 2017 marked the first time that Cermak achieved substantial compliance with all 21 provisions of the Agreed Order. At that time, the Monitoring Team encouraged Cermak to continue on their path to continued system improvement and warned Cermak against complacency. We are happy to report that Cermak has embraced the continued system improvement mantra and has sustained substantial compliance in every element of the agreed order since our last visit. An area that deserves a special mention is the creation of EHR based health services request scheduling and tracking tool and dashboard which allows Cermak to have real time understanding of health service request forms that have gone unanswered past a specific deadline. We believe this to be a best in class initiative and one that we hope Cermak will share with the rest of the correctional health care providers in this country.
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All provisions previously in substantial compliance remained in substantial compliance. This means that at this time, all provisions of the agreed order have remained in substantial compliance for at least 6 months. There are still, however, opportunities for improvement with respect to classification and documentation of nurse triage decisions, quality of nursing assessments and related documentation. We also have concerns about timely access of patients with urgent dental complaints and a breakdown of access to care in selected areas of the jail. These areas must be adequately addressed prior to the next monitoring visit to maintain substantial compliance in access to care.
As discussed in our exit meeting, the Monitoring Team would like to congratulate Cermak and CCDOC for their continued commitment to maintaining a robust and functional partnership that is with no doubt one of the main reasons for the continued success and efficacy of both entities in the provision of correctional health care services in a safe environment.
Considering the current status of Cermak with regard to the achievement of substantial compliance with all the provisions of the agreed order, the Monitoring Team will continue with its abbreviated visit of two full days with only four monitors. Our next visit is currently scheduled for the week of April 30th, 2018 with the exit conference scheduled for 9am on Wednesday May 2nd.
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Introduction and Report Organization On November 14, 2017, the population of Cook County Jail was reported as 6,434. There
were another 2,205 inmates listed under “Community Corrections Population” bringing the total under custody population to 8,639. This was the lowest census at Cook County Jail since this Monitoring Team began visiting Cermak four years ago. Definitions and Organization
This report is formatted in the manner requested by the Department of Justice and closely follows the Agreed Order. The report includes four parts for each section of the Agreed Order.
In part one; we rewrite verbatim the pertinent portion of the Agreed Order. This first part is labeled Remedial Measure of Agreed Order.
The second part is the overall compliance rating labeled Compliance Assessment. This is the assessment that the Monitoring Team experts make based on judgment, data, and chart reviews. Throughout this Agreed Order, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance: “Substantial Compliance” indicates that the relevant Defendant(s) has achieved compliance with most or all components of the relevant provision of the Agreed Order. “Partial Compliance” indicates that compliance has been achieved on some of the components of the relevant provision of the Agreed Order, but significant work remains. “Non-compliance” indicates that most or all of the components of the Agreed Order provision have not yet been met. Non-compliance means that much work needs to be done before compliance is met. When indicated, the Monitoring Team will additionally assess the various components (sub-bullet points) of certain sections of the Agreed Order. Our goal is to highlight areas of success and bring focus to areas that need further refining and attention.
4

Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 6 of 56 PageID #:5609 The third part is the factual basis for forming the opinion in the Compliance Assessment.
This will be as data driven as possible. For patient care areas, chart reviews form a substantial portion of this review. Touring, interviews, and reviewing data sources is also an important means of making assessments.
The fourth part is our recommendations. These recommendations are our view of what needs to be accomplished to attain and maintain compliance. This will include the Monitoring Team’s recommendations for self-monitoring activities and audits.
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HEALTH CARE SERVICES: ELEMENTS COMMON TO MEDICAL AND MENTAL HEALTH 41. Inter-Agency Agreement
a. CCDOC shall enter into a written Inter-Agency Agreement with Cermak that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
b. Cermak shall enter into a written Inter-Agency Agreement with CCDOC that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Monitor’s Findings:
Spot checking showed no lapses in compliance. Monitor’s Recommendations:
None. 42. Policies and Procedures
Cermak shall provide adequate services to address the serious medical and mental health needs of all inmates, in accordance with generally accepted professional standards. The term “generally accepted professional standards” means those industry standards accepted by a
6

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majority of professionals in the relevant field, and reflected in the standards of care such as those published by the National Commission on Correctional Health Care (“NCCHC”).
a. Cermak shall develop and implement medical care policies, procedures and practices to address and guide all medical care and services at the Facility, including, but not limited to the following: i. access to medical care ii. continuity of medication iii. infection control iv. medication administration v. intoxication and detoxification vi. documentation and record keeping vii. disease prevention viii. sick call triage and physician review ix. intake screening x. chronic disease management xi. comprehensive health assessments xii. mental health xiii. women’s health xiv. quality management xv. emergent response xvi. infirmary care xvii. placement in medical housing units
xviii. handling of grievances relating to health care
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xix. mortality review xx. care for patients returning from off-site referrals c. Cermak shall develop and implement policies, procedures and practices to ensure timely responses to clinician orders including, but not limited to, orders for medications and laboratory tests. Such policies, procedures and practices shall be periodically evaluated to ensure timely implementation of clinician orders. Compliance Status: This provision remains in substantial compliance. Monitor’s Findings: A printed copy of the existing Cermak policy and procedures was reviewed. Policy and procedures were either up to date or had recently been revised so no recent staff education on revised policies had occurred. There were no new policies since our last visit in April 2017. The Monitoring Team specifically asked for and received current policy and procedures for NonEmergent Health Care Requests and Services (last revision May 2017). We find this policy up to date and generally aligned with the NCCHC standards with one minor exception with regard to urgent health care requests and services. Monitor’s Recommendations: The Monitoring Team recommends the creation of a new policy for handling of urgent health care requests. 43. Medical Facilities a. CCDOC will work with Cermak to provide sufficient clinical space, as identified by Cermak staff, to provide inmates with adequate health care to meet the treatment needs of
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detainees, including: intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. b. Cermak shall make known to CCDOC and Cook County its needs for sufficient clinical space, with access to appropriate utility and communications capabilities, to provide inmates with adequate health care to meet the treatment needs of inmates including: intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. c. Cook County shall build out, remodel, or renovate clinical space as needed to provide inmates with adequate health care to meet the treatment needs of detainees as identified by Cermak staff including: intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. d. Cermak shall ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in examination rooms. Cermak shall ensure that hand washing stations in medical care areas are fully, equipped, operational and accessible. e. Cermak shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and medical tools) and hazardous waste. f. CCDOC shall allow operationally for inmates reasonable privacy in medical and mental health care, and shall respect the confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically
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includes sight and hearing privacy from other inmates, and hearing privacy from staff that are not providing care. g. Cermak shall make known to CCDOC and Cook County the structural and operational requirements for inmates’ reasonable privacy in medical and mental health care. Cermak shall provide operationally for inmates’ reasonable privacy in medical and mental health care and shall respect the confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically includes sight and hearing privacy from other inmates, and hearing privacy from staff that are not providing care. h. Cook County shall build out, remodel or renovate clinic space as needed to allow structurally for inmates’ reasonable privacy in medical and mental health care, as identified by Cermak and CCDOC staff. i. Cook County shall begin construction of the new clinical space within 3 months of the effective date of this Agreed Order. It is expected that the project will be completed within nine months of the effective date of this Agreed Order. Prior to the completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding clinical space, to the extent possible in the current facility. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such is no longer being monitored except for spot check monitoring as indicated. Monitor’s Findings: Spot checking showed that medical facilities remain in substantial compliance.
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Monitor’s Recommendations: Sustain improvements in clinic organization and sanitation. Ensure that environmental
cleaning takes place as scheduled in the Divisions and Cermak administrative areas. 44. Staffing, Training, Supervision and Leadership
a. Cermak shall maintain a stable leadership team that clearly understands and is prepared to move forward toward implementation of the provisions of this Agreed Order, with respect to: i. Medical care; and ii. Mental health care
b. Cermak shall maintain an adequate written staffing plan and sufficient staffing levels of health care staff to provide care for inmates’ serious health needs, including: i. Qualified Medical Staff; and ii. Qualified Mental Health Staff.
c. Cermak shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious health care needs of inmates. All such staff shall receive documented orientation and in-service training on relevant topics, including: i. Provision of health care in a correctional setting and Facility-specific issues; and ii. Suicide prevention, and identification and care of inmates with mental illness.
d. Cermak shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.
e. Cermak shall ensure that all persons providing health care meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and
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licensure. Upon hiring and annually, Cermak shall verify that all health care staff have current, valid, and unrestricted professional licenses and/or certifications for:
i. Medical staff; and ii. Mental health staff f. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on recognition and timely referral of inmates with medical urgencies, including drug and alcohol withdrawal. Cermak will provide adequate initial and periodic training on these topics to all Cermak staff who work with inmates. g. CCDOC will provide, to all CCDOC staff who work with inmates, adequate initial and periodic training on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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. h. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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
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Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 14 of 56 PageID #:5617
illness. Such training shall be conducted by a Qualified Mental Health Professional, registered psychiatric nurse, or other appropriately trained and qualified individual. i. Cermak shall ensure that all health care staff receive adequate training to properly implement the provisions of this Agreed Order, including:
a. Medical staff; and b. Mental health staff. Compliance Status: This provision remains in substantial compliance. Monitor’s Findings: 1. Since our last visit in April 2017, Cermak has a new permanent Director of Quality Improvement. There has been a net of 19 new hires since our last visit consisting of 67 new hires and 48 new vacancies (transfers, resignations, retirements, terminations, etc.). The overall vacancy rate across Cermak is currently at 13% or 88 total vacancies (594 out of 682 total positions filled). This compares to 16% vacancy rate in April 2017 (576 out of 683 total positions). One Cermak Administrative position was transferred out of Cermak. No new positions have been added. The vacancy rate for med/surg has increased to 18% compared to 16% in April 2017. This, however, reflects two recent retirements which are expected to be filled in the next 6 weeks. All Advanced Practice Provider (PA) positions except one continue to be filled. Six of 20 Attending physician positions remain vacant (no change from April 2017). Nursing vacancy has decreased to 12% compared to 13% in April 2017. . Cermak continues to utilize overtime, contract labor (moonlighting, locums, etc.) and part time staffing to meet their provision of health service needs.
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2. The Monitoring Team did not review the annual training, Ongoing Professional Practice Evaluation (OPPE) or the credentialing files of Cermak professional staff since this provision has been in substantial compliance for more than 18 months.
3. The Monitoring Team met with the Executive Director CCDOC, toured several of the housing divisions and interviewed several Cook County inmates including three inmates in the Special Management Unit (SMU). CCDOC has expanded the officer training from every 18 months to every 12 months of 24 hours of training per officer. The Monitoring Team reviewed the list of the training topics.
4. We did not review ongoing initial and interval training of CCDOC officers as this provision has been in substantial compliance for more than 18 months.
5. While the Monitoring Team is encouraged about the continued drop in the inmate census at the Cook County Jail, we remain vigilant that staffing and processes of care at the jail continue to meet the needs of the detainee population.
Monitor’s Recommendations: 1. Continue to fill all vacant positions to further improve the provision of health care as well as to reduce the utilization of overtime and contract labor. 2. Maintain/improve vacancy rate across the system but especially in nursing.
45. Intake Screening a. Cermak shall maintain policies and procedures to ensure that adequate medical and mental health intake screenings are provided to all inmates.
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b. Cermak shall ensure that, upon admission to the Facility, Qualified Medical Staff or Licensed Correctional Medical Technicians utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, shall assess and document the inmate’s vital signs, and shall seek the inmate’s cooperation to provide information, regarding: (1) medical, surgical and mental health history, including current or recent medications, including psychotropic medications; (2) history and symptoms of chronic disease, including current blood sugar level for inmates reporting a history of diabetes; (3) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use; (4) history of substance abuse and treatment; (5) pregnancy; (6) history and symptoms of communicable disease; (7) suicide risk history; and (8) history of mental illness and treatment, including medication and hospitalization.
c. Cermak shall ensure that, upon admission to the Facility, Qualified Mental Health Staff, Qualified Medical Staff, or Licensed Correctional Medical Technicians utilize an appropriate mental health intake screening instrument to identify and
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Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 17 of 56 PageID #:5620
record observable and non-observable mental health needs, and seek the inmate’s cooperation to provide information, 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) previously identified suicide risk during any prior confinement at CCDOC; (6) any observations of the transporting officer, court, transferring agency or
similar individuals regarding the inmate’s potential suicide risk, if such information is communicated to Cermak staff; (8) psychotropic medication history; and (9) alcohol and other substance use and withdrawal history. d. Cermak shall ensure that all Qualified Mental Health Staff, Qualified Medical Staff or Licensed Correctional Medical Technicians who conduct the medical and mental health intake screenings are properly trained on the intake screening process, instrument, and the requirements and procedures for referring all qualifying inmates for further assessment. e. If Cermak assigns Licensed Correctional Medical Technicians to perform intake screening, they shall receive appropriate, on-site supervision by on-site Qualified Medical Staff; information obtained on screening for all inmates will be reviewed by Qualified Medical Staff before the inmate departs the intake area.
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f. Cermak shall ensure that a medical assessment based on the symptoms or problems identified during intake screening is performed within two working days of booking at the Facility, or sooner if clinically indicated, by a Qualified Medical Professional for any inmate who screens positively for any of the following conditions during the medical or mental health intake screenings: (1) Past history and symptoms of any chronic disease included on a list specified by Cermak’s policies and procedures; (2) Current or recent prescription medications and dosage, including psychotropic medications; (3) Current injuries or evidence of trauma; (4) Significantly abnormal vital signs, as defined by Cermak’s policies and procedures; (5) Risk of withdrawal from alcohol, opioid, benzodiazepine, or other substances; (6) Pregnancy; (7) Symptoms of communicable disease; and (8) History of mental illness or treatment, including medication and/or hospitalization.
g. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake process receives a comprehensive mental health evaluation (see provision 59.c, “Mental Health: Assessment and Treatment”) Cermak shall ensure timely access to a Qualified Mental Health 17

Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 19 of 56 PageID #:5622
Professional for this purpose, based on emergent, urgent, and routine medical or mental health needs. h. Cermak shall ensure that the intake health screening information is incorporated into the inmate’s medical record in a timely manner. i. Cermak shall implement a medication continuity system so that incoming inmates’ medication for serious medical and mental needs can be obtained in a timely manner, as medically appropriate. Within 24 hours of an inmate’s booking at the Facility, or sooner if medically necessary, a Qualified Medical Professional or Qualified Mental Health Professional, with appropriate prescribing authority, shall decide whether to continue the same or comparable medication for serious medical and mental health needs that an inmate reports during intake screening that she or he has been prescribed. If the inmate’s reported medication is discontinued or changed, other than minor dosage adjustments or substitution of a therapeutic equivalent, a Qualified Medical Professional or Qualified Mental Health Professional, with appropriate prescribing authority, shall evaluate the inmate face-to-face as soon as medically appropriate, and within no greater than five working days, and document the reason for the change. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such is no longer being formally monitored except for spot check monitoring as indicated.
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Monitor’s Findings: Spot checking showed that this area remains in substantial compliance.
Monitor’s Recommendations: Perform periodic CQI studies to ensure that patients continue to receive timely
and appropriate care at intake. 46. Emergency Care
a. Cermak shall train health care staff to recognize and respond appropriately to health care emergencies, including: (1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
b. CCDOC shall train correctional officers to recognize and respond appropriately to health care emergencies, including: (1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
c. CCDOC shall ensure that all inmates with emergency health care needs receive prompt transport, including transport for outside care, for emergencies including: (1) Medical emergencies; and (2) Mental health emergencies. 19

Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 21 of 56 PageID #:5624
d. Cermak shall ensure that all inmates with emergency health care needs receive timely and appropriate care, with prompt referrals for outside care when medically necessary, and shall notify CCDOC when emergency transport is needed inside or outside the Facility compound, for emergencies including: (1) Medical emergencies; and (2) Mental health emergencies.
e. CCDOC shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation (“CPR”) and addressing serious bleeding) in emergency situations. CCDOC shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
Compliance Status: This provision remains in Substantial Compliance.
Status Update: Received and reviewed.
Monitor’s Findings: Cermak has documentation to reflect that the staff has been trained in Emergency Care
Procedures. The correctional officers have been trained with regards to medical emergencies and mental health emergencies.
Patients sent to the urgent care are tracked using the Cerner electronic medical record. Chart audit shows that there are some delays in bringing the patient to the urgent care from their housing units. There is also some delay to see the physician once they arrive to the urgent care.
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There is variation between the acuity level assigned in the housing unit and the one assigned in the urgent care. This can be due to change in the patients’ clinical status at each of the locations.
The documentation of the encounter is consistently done in the electronic medical record. The orders are also entered directly into the electronic medical record. The assessments and treatment plan was appropriate. The patients were sent to the appropriate housing location upon discharge from the urgent care.
Hypoglycemic events are being monitored and addressed consistently. The clinical pharmacist routinely reviews the hypoglycemic events and addresses them timely. The hypoglycemia template for nursing has been implemented and has helped improve documentation of the event.
The critical lab results are addressed in a timely manner by the providers. A report has been established to monitor the process. Monitor’s Recommendations:
1. Monitor time from when the patient was referred to the urgent care to when the patient was triaged in the urgent care
2. Monitor time from triage to provider evaluation 3. Educate staff regarding assignment of acuity scores 4. Perform chart audits for urgent care visits to identify opportunities for improvement
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47. Record Keeping a. Cermak 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 the Facility and are maintained consistent with local, federal, and state medical records requirements. b. Cermak 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. c. To ensure continuity of care, Cermak shall submit appropriate medical information to outside medical providers when inmates are sent out of the Facility for medical care. Cermak shall appropriately request 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. d. Cermak shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
Compliance Status: This provision remains in substantial compliance (since November 2016)
Status Update: All elements of record keeping remain in compliance.
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Monitor’s Findings: All requirements to fix the problem of erroneous discharges have been identified since our
last monitoring visit. However, funding that CCHHS had allocated for the project is no longer available. Although it was Cermak’s intention to proceed with repairs, the project remains onhold. As of November 2017, all errors continue to be manually addressed. Each day, discrepancies between Cook County Offender Management System (CCOMS) and Cerner are identified. Cermak then reactivates the records of any inmates who have not been discharged from the facility and notifies the medical staff of orders which need to be re-entered. From August 1 through October 31, 2017 there have been 7 erroneous discharges. Close daily monitoring and follow up on the part of Cermak prevents delays and omissions in care due to the sometimes inaccurate information exchange between the CCOMS and Cerner systems.
In May of 2017 documentation of medication administration was in transition from Accuflow to documentation of all medications in Cerner medication administration record. As of this report this transition has been completed. Accuflow is no longer being utilized.
Cermak investigated and found that it is not possible to eliminate auto-cancellation of lab orders in the Cerner system. Instead the Health Information Technology (HIT) staff are working with the medical staff to resolve the problem by using the task list to order labs in advance of scheduled appointments. In addition, the nursing department has trained nurses to assist with the collection of labs to prevent auto-cancelation.
Other improvements Cermak is currently working on include: The implementation of Individualized Plan of Care (IPOC) for both the special care unit and mental health has been in place since October 31, 2017.This program creates an individualized care plan based on patient
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problems and acuity. The IPOC program also provides prompts for nursing staff to ensure adequate record keeping and timely updates.
Cermak has completed revisions to documentation templates for nursing assessment of patients seen for evaluation of health service request forms (HSRs). The form is being piloted in Division 4. Progress will be reported to the monitoring team before the new HSR is implemented in all divisions.
System downtime as reported in the eMERS incident reporting system is infrequent and almost entirely due to issues with Accuflow. There has been one incident reported since August 1, 2017 in division 4 nursing cart due to no system connection. Procedures are in place requiring paper documentation when the automated health record is down. Monitor’s Recommendations:
None. 48. Mortality Reviews
a. Cermak shall request an autopsy, and related medical data, for every inmate who dies while in the custody of CCDOC, including inmates who die following transfer to a hospital or emergency room.
b. Relevant CCDOC personnel shall participate in Cermak’s mortality review for each inmate death while in custody, including inmates who die following transfer to a hospital or emergency room, 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 seek to determine whether there was a systemic or specific problem that may have
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Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 26 of 56 PageID #:5629
contributed to the incident. At a minimum, CCDOC’s contribution to mortality and morbidity reviews shall include:
I. Critical review and analysis of the correctional circumstances surrounding the incident;
II. Critical review of the correctional procedures relevant to the incident; III. Synopsis of all relevant training received by involved correctional staff; IV. Possible precipitating correctional factors leading to the incident; and V. Recommendations, if any, for changes in correctional policy, training, physical
plant, and operational procedures. c. Cermak shall conduct a mortality review for each inmate death while in custody,
including inmates who die following transfer to a hospital or emergency room, and a morbidity review for all serious suicide attempts or other incidents in which an inmate was at high risk for death. Cermak shall engage relevant CCDOC personnel in mortality and morbidity reviews 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:
I. Critical review and analysis of the circumstances surrounding the incident; II. Critical review of the procedures relevant to the incident; III. Synopsis of all relevant training received by involved staff; IV. Pertinent medical and mental health services/reports involving the victim; V. Possible precipitating factors leading to the incident; and
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VI. Recommendations, if any, for changes in policy, training, physical plant, medical or mental health services, and operational procedures.
d. Cermak shall address any problems identified during mortality and morbidity reviews through timely training, policy revision, and any other appropriate measures.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Received and reviewed. Monitor’s Findings:
There have been five death-in-custody cases since our last visit in April 2017 including one suicide. The mortality review/ root cause analysis (RCA) for all deaths in custody cases were reviewed by the Monitoring Team. We found the RCAs to be comprehensive and multidisciplinary with succinct action plan items. Monitor’s Recommendations:
Continue to place focused attention on prevention of suicide deaths. 49. Grievances
Cermak shall develop and implement policies and procedures for appropriate handling of grievances relating to health care, when such grievances are forwarded from CCDOC. Compliance Status:
This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot checking. Spot check was conducted.
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Status Update: None.
Monitor’s Findings: Spot check showed no lapses in compliance.
Monitor’s Recommendations: None.
C. MEDICAL CARE 50. Health Assessments a. Cermak shall ensure that Qualified Medical Professionals attempt to elicit the amount,
frequency and time since the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. b. Cermak shall ensure that incoming inmates who present and are identified by medical personnel as having either a 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 or Qualified Mental Health Staff with appropriate, on-site supervision 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. c. Cermak shall ensure that all inmates at risk for, or demonstrating signs and symptoms of, drug and alcohol withdrawal are timely identified. Cermak shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.
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d. CCDOC shall maintain a policy 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.
e. Cermak shall ensure that the medical assessment performed within two working days of his or her booking at the Facility, or sooner if clinically indicated, for each inmate specified above (provision 45.f, “Intake Screening”) shall include a review of the inmate’s intake screening form, a medical history, a physical examination, a mental health history, and a current mental status examination. The physical examination shall be conducted by a Qualified Medical Professional. The medical assessment shall also include development or revision of the inmate’s problem list and treatment plan to address issues identified during the medical assessment. 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 medical assessment within the previous six months and whose receiving screening shows no change in the inmate’s health status need not receive a new medical assessment. For such inmates, Qualified Medical Staff shall review prior records and update tests and examinations as needed.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot checking.
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Monitor’s Findings: Spot checking showed that this area remains in substantial compliance.
Monitor’s Recommendations: 1. Cermak leadership should continue periodic CQI studies assessing the appropriateness,
timeliness and quality of care. 2. The QI program should continue to monitor the documentation of timely receipt of
medications that are deemed critical. 51. Acute care 51a. Urgent Care
Cermak 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 care will include timely medical appointments and follow-up medical treatment. Compliance Status:
This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
The Monitoring Team was provided a status update prior to our visit. Monitor’s Findings:
Spot checking showed no lapses in compliance.
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Monitor’s Recommendations: None.
51b. Acute Care-Infirmary a. Cermak shall maintain guidelines for the scope of care of acutely ill patients in its on-site designated infirmary units and for transfer of patients when appropriate to outside hospitals.
Compliance Status: This provision remains in Substantial Compliance
Status Update: Received and reviewed.
Monitor’s Findings: Record reviews, patient and staff interviews were conducted to evaluate the care in the Infirmary. The team is functioning well. Nursing staff have a shift report to review each patient in their area during shift change. The physicians and nurses participate in the morning huddle to discuss overnight issues, new admissions, etc. The staff are very engaged and performing well. The patients are appropriately admitted to the infirmary. The initial nursing and provider assessments are done timely. The nursing and provider acuity levels are assigned and updated routinely. Nursing has developed documents to keep track of patients’ condition and needs. This document is used during the shift report and the huddle with the provider. The nursing staff has too many places to document and can benefit from an optimization effort. The infirmary was clean. The infirmary census was reasonable and there were no boats used in this location.
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Monitor’s Recommendations: Review nursing work flow and documentation to identify opportunities for optimization.
52. Chronic Care a. Cermak shall maintain an appropriate, written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring and continuity of care consistent with the inmates’ expected length of stay. b. Cermak shall maintain appropriate written clinical practice guidelines for chronic diseases, such as HIV, hypertension, diabetes, asthma and elevated blood lipids. c. Cermak shall maintain an updated registry to track all inmates with serious and/or chronic illnesses and shall monitor this registry to ensure that these inmates receive necessary diagnoses and treatment. Cermak shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates’ individual medical records. d. Cermak shall ensure that inmates with chronic conditions are routinely seen by a physician, physician assistant, or advanced practice nurse to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions. e. CCDOC shall house inmates with disabilities, or who need skilled nursing services or assistance with activities of daily living, in appropriate facilities, as determined by Cermak. CCDOC shall permit inmates with disabilities to retain appropriate aids to impairment, as determined by Cermak. f. Cermak shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. Cermak shall notify CCDOC of their specific needs for housing and aids to impairment.
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g. Cook County shall build out, remodel, or renovate clinical space as needed to provide appropriate facilities for inmates with disabilities in accordance with the timelines set out in provision 43.i. Prior to completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding facilities for inmates with disabilities, to the extent possible in the current Facility.
Compliance Status: This provision remains in Substantial Compliance
Status Update: Received and reviewed.
Monitor’s Findings: The Monitoring Team reviewed health records of chronic disease patients. Cermak has a
chronic disease management plan and several clinical practice guidelines to help the provider use best practices in the management of chronic diseases. Cermak has developed and implemented several order sets for common chronic diseases. This ensures that the required orders are placed for the patient and avoids human error. The Power note templates are consistently used by the providers. The template guides the providers to document all relevant aspects of the evaluation and care plan.
The patients with chronic disease are identified in the medical records to help the clinical team to monitor them. Each provider performs peer review to check compliance with their established clinical practice guidelines. The results are shared with the staff and used for improvement activities.
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Record review showed that HIV patients were medically screened in a timely manner and referred for a secondary health assessment. HIV providers saw patients timely following their arrival. At the initial appointment, clinicians performed a history and physical examination and ordered labs in accordance with current guidelines, with the exception that QuantiFeron testing was performed only in 3 of 5 patients. Providers assessed patients’ readiness to begin or restart antiretroviral therapy and prophylaxis for opportunistic infections was initiated when clinically indicated. Medication administration Records (MAR’s) generally show that patients are adherent with occasional missed doses due to refusals or being off the tier. At follow-up visits, HIV providers reviewed pertinent lab test results and counseled patients. Overall, we found HIV care to be timely and appropriate.
Medical provider visits are scheduled timely by the scheduling team. Reports have been created to monitor the process. The nurses have been trained to draw blood and they try to get the blood drawn when the patient is in the clinic. This avoids the extra transport and also helps ensure that the blood draw is done timely. Extensive reports have been developed to monitor the process. A lot of effort has been put into improving the scheduling of the medical provider visits and the phlebotomy visits. They have drastically reduced the auto cancelled labs through successful implementation of the project.
The patients who need assistance with activities of daily living are receiving appropriate care. Cermak and CCDOC are collaborating well to address any specific housing needs and aids to impairment. Cermak has adequate clinical space to take care of patients with disabilities. Monitor’s Recommendations:
Continue established audits and reports.
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53. Treatment and Management of Communicable Diseases a. Cermak shall maintain adequate testing, monitoring and treatment programs for management of communicable diseases, including tuberculosis (“TB”), skin infections, and sexually transmitted infections (“STIs”). b. CCDOC shall comply with infection control policies and procedures, as developed by Cermak, that address contact, blood borne, and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs, consistent with generally accepted correctional standards of care. c. Cermak shall maintain 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, consistent with generally accepted correctional standards of care. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates. d. Pursuant to Centers for Disease Control (“CDC”) Guidelines, Cermak shall continue to test all inmates for TB upon booking at the Facility and shall follow up on test results as medically indicated. Cermak shall follow current CDC guidelines for management of inmates with TB infection, including providing prophylactic medication when medically appropriate and consistent with the inmate’s expected length of stay. Inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB and housed in an appropriate, specialized respiratory isolation (“negative pressure”) room. Cermak shall notify CCDOC of inmates’ specific
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housing requirements and precautions for transportation for the purpose of infection control. e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing. f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems. g. Cermak 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. h. Cermak shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot check monitoring as indicated. Status Update: Status update received and reviewed. Monitor’s Findings: Spot checking showed no lapses in compliance. Monitor’s Recommendations: None.
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54. Access to Health Care a. CCDOC will work with Cermak to facilitate timely and adequate accessibility of appropriate health care for inmates, as provided by Cermak. b. Cermak shall ensure the timely and adequate availability of appropriate health care for inmates. c. Cermak 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. written medical and mental health care slips available in English, Spanish and other languages, as needed; ii. opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and iii. opportunity for all inmates, irrespective of primary language, to access medical and mental health care. d. Cermak shall ensure that the sick call process includes confidential collection, logging and tracking of sick call requests seven days a week. Cermak shall ensure timely responses to sick call requests 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
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appointment. Cermak shall document the reason for and disposition of the medical or mental health care request in the inmate’s medical record. e. Cermak shall develop and implement an effective system for screening medical requests within 24 hours of submission. Cermak shall ensure that sick call requests are appropriately prioritized based upon the seriousness of the medical issue. f. Cermak shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting. g. Cermak 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. Compliance Status: This provision remains in substantial compliance. Status Update: The Monitoring Team was provided and reviewed access to care data in preparation for the November 2017 Monitoring Tour. Monitor’s Findings: The Monitoring Team evaluated inmate access to care by reviewing health service request tracking systems; randomly inspecting health care request form availability; reviewing health service request (HSR) forms, health records, nurse protocols, observing nursing sick call
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encounters, and interviews with staff and inmates. In addition, Cermak health care leadership presented results of CQI studies and ongoing audits regarding access to care. At the last monitoring visit in April 2017, all elements of Access to Care came into substantial compliance. Substantial compliance was sustained at this monitoring visit.
The monitoring team reviewed a sample of approximately 110 health services requests (HSR) from all divisions submitted by inmates from August 15 to November 5 2017. The monitoring team selected HSRs from sick call and chronic disease logs and from HSRs forwarded to Health Information Management (HIM) for scanning into the electronic medical record (EMR).
We found that staff timely collected and signed HSRs upon receipt. Nurses timely triaged HSR’s and legibly dated forms. Nurses did not consistently document triage dispositions on the form. When nurses did document triage dispositions (e.g., urgent/routine) they were not consistently appropriate to the urgency of the patient’s complaint.
Health care leadership is piloting a HSR form with a revised triage disposition section. Triage options for the nurse are not based upon a clinical determination (i.e., emergent, urgent, routine) but rather an action disposition (i.e., to see the patient today or within 48-72 hours). The monitoring team believes this approach will lead to clinical judgement errors and strongly recommend that triage dispositions are based upon clinical urgency. In addition, each Nursing Guideline contains criteria for the urgency of nurse to provider referrals, but do not contain criteria for the urgency of nurse triage dispositions. We recommend that health care leadership develop criteria for the urgency of dispositions and train nurses to these criteria.
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In most Divisions nurses saw patients within required time frames. However, there were instances in which nurses did not timely see patients or where we found discrepancies in the documentation of such encounters. We discussed these issues with nursing leadership during the monitoring visit.
We found a lack of consistency across the jail regarding the management of patients with dental complaints (See 58. Dental Care) including the timely assessment of patients with urgent dental complaints or timely referral of such patients to the dentist.
Positively, health care leadership is piloting a process in Division 4 intended to facilitate access to dental care. When patients submit HSR’s with a dental complaint, a nurse is to see the patient, treat the patient according to a nursing guideline, and provide the patient a Dental NonEmergency Secondary Health Service Request that is printed on green paper. It is essentially a second request for access to dental care related to pain. Patients are instructed not to submit this form for 10 days after seeing the nurse. Upon receiving the form, nurses are to perform a wellbeing check and refer the patient to dental services. However, this process does not appear to expedite access to dental services. While patients can freely submit new HSR to seek help if their condition changes, it is a concern that patients are instructed not to submit the green HSR forms for 10 days following the nurse’s evaluation, as the patient’s pain may not be adequately managed by nursing guideline measures or may have become complicated by infection.
Nurses documented assessments into Cerner using nursing protocols. As noted in previous visits, the quality of nursing assessments is variable and often not consistent with Cermak Nursing Guidelines and/or good clinical judgement. The lack of adequate nursing assessments was mitigated by nurses more frequently consulting and/or referring patients to providers.
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The Agreed Order 54 (d.) requires that “Cermak log and track sick call requests seven days a week…. 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. Cermak shall document the reason for and disposition of the medical or mental health care request in the inmate’s medical record”.
Since the last site visit, healthcare leadership has developed an electronic health record (EHR) based tracking system for each HSR. This will permit real-time tracking regarding the status and disposition of every HSR and focus and facilitate quality improvement activities. We commend health care leadership for this process.
Compliance with the Agreed Order is further described below. a. Remains in substantial compliance.. CCDOC has developed a report regarding the status of
inmate appointments that is updated throughout the day. Both custody and health care staff use this report to monitor the status of inmate appointments and take action to ensure they are completed. This is an excellent tool. b. Remains in substantial compliance. As noted above, while access to care continues to improve across the jail, focused improvements to access to care are needed in outlier divisions and with respect to access to dental care. c. Remains in substantial compliance.. We found that housing tiers contained adequate supplies of Health Services Request forms in English and Spanish. d. Remains in substantial compliance.. Staff collects HSR forms daily and contemporaneously maintains HSR tracking logs in sick call boxes. As noted above, the current HSR Daily
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Summary needs to be amended to fully account for the disposition of HSRs received each day. e. Remains in substantial compliance. Nurses triaged and legibly signed HSR’s within 24 hours. However, nurses did not consistently document triage decisions which should be done in order to prioritize the order in which patients are seen. We recommend that triage dispositions are clinically based rather than action based. f. Remains in substantial compliance. Nurse sick call is conducted in adequately equipped and supplied examination rooms. g. Remains in substantial compliance. CCDOC has increased out of cell time for inmates that are segregated from general population inmates. The goal is for these inmates to be out of cell for 3 of every 24 hours with concomitant increases in staff and inmate interaction thus reducing their social isolation and frequency of medical and/or mental health rounds, reducing the need for round to weekly. CCDOC has developed an electronic data base that enables them to monitor and demonstrate compliance with out of cell time for each inmate. We did not review data during this visit. Health care leadership reported that inmates were consistently out of cell for greater than 3 hours. Recommendations: 1. Health care leadership and CCDOC should continue to study and identify root causes of
delays in access to care when they arise to include consideration of nurse vacancies, staff reassignments, lack of officers or custody/nurse or provider scheduling. 2. Nurses should document a triage disposition on each HSR in accordance with nursing protocols and prioritize patients with urgent requests to be seen first.
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3. Nurse triage dispositions should be based upon clinical urgency rather than nurse actions. Health care leadership should develop criteria for emergent, urgent and routine triage dispositions and train nurses to these criteria.
4. Health care leadership and nurse managers should continue to perform CQI studies regarding nursing performance to provide feedback to nurses.
5. Nurses should assess all patients with dental pain and refer to dental in accordance with the urgency of the complaint.
55. Follow-Up Care a. Cermak shall provide adequate care and maintain appropriate records for inmates who return to the Facility following hospitalization or outside emergency room visits. b. Cermak shall ensure that inmates who receive specialty, emergency room, or hospital care are evaluated upon their return to the Facility 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.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot checking. Status Update:
Received and reviewed.
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Monitor’s Findings: The Monitoring Team reviewed health records of patients returning from hospitalization
and emergency room visits. Patients returning from the hospital emergency department or inpatient units are brought
to the urgent care clinic and are seen by the urgent care provider. The medical and CCDOC staff are following the established process. The urgent care providers are consistently reviewing the hospital records and address their recommendations. The patients are sent to the appropriate housing based on their health needs. The Providers in the housing units also see the patient upon return from the hospital to ensure continuity of care.
The Nursing managers and Physician leaders collaborate to ensure a safe transition of care from the hospital to the Jail. Monitor’s Recommendations:
Continue with the established audits and reports. 56. Medication Administration
a. Cermak shall ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted correctional standards of care.
b. Cermak shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. Cermak 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. Cermak shall ensure that medicine administration is hygienic, appropriate for the needs of inmates and is recorded concurrently with distribution. 43

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d. Cermak shall ensure that medication administration is performed by Qualified Nursing Staff.
e. When Cermak prescribes medication to address an inmate’s serious mental health needs, HIV or AIDS, or thromboembolic disease, Cermak shall alert CCDOC that the inmate in question is on a flagged medication. If the prescription is terminated during an inmate’s stay at the Facility, Cermak will notify CCDOC.
f. When CCDOC receives notice that an inmate is on a flagged medication, CCDOC shall include notation of a medication flag in the inmate’s profile on the Facility’s Jail Management System.
g. When an inmate with a medication flag is processed for discharge at the Facility, CCDOC shall escort the inmate to designated Cermak staff in the intake screening area of the Facility for discharge medication instructions.
h. When CCDOC escorts an inmate with a medication flag to Cermak staff during discharge processing, Cermak staff shall provide the inmate with printed instructions regarding prescription medication and community resources.
i. Each morning, CCDOC shall provide Cermak with a list of all inmates with medication flags who were discharged the previous day.
j. Within 24 hours of discharge of an inmate with a medication flag, Cermak shall call in an appropriate prescription to the designated pharmacy on the Stroger Hospital campus to serve as a bridge until inmates can arrange for continuity of care in the community.
k. CCDOC shall ensure that information about pending transfers of inmates is communicated to Cermak as soon as it is available.
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l. When CCDOC has advance notice and alerts Cermak of the pending transfer to another correctional facility of inmates with serious medical or mental health needs from detention, Cermak shall supply sufficient medication for the period of transit. In such cases, Cermak shall prepare and send with transferring inmates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Facility.
m. CCDOC shall ensure that the transfer summary and any other medical records provided by Cermak will accompany inmates, or will be made available electronically or transmitted by facsimile, when they are transferred from the Facility to another institution.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Status update received and reviewed. Monitor’s Findings:
Spot checking showed no lapses in compliance. Monitor’s Recommendations:
None 57. Specialty Care Cermak shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at the Facility shall receive timely and appropriate referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
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a. Upon reasonable notification by Cermak, CCDOC will transport inmates who have been referred for outside specialty care to their appointments.
b. Cermak 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. Cermak shall provide reasonable notice to CCDOC of such appointments so that CCDOC can arrange transportation. Inmates waiting outside care shall be seen by Qualified Medical Staff as medically necessary, at clinically appropriate intervals, to evaluate the current urgency of the problem and respond as medically appropriate. If an inmate refuses treatment following transport for a scheduled appointment, Cermak shall have the inmate document his refusal in writing and include such documentation in the inmate’s medical record.
c. Cermak 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. Cermak shall ensure that pregnant inmates are provided adequate pre-natal care. Cermak shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment and management of highrisk pregnancies.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot checking.
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Status Update: Received and reviewed.
Monitor’s Findings: The Monitoring Team reviewed health records of patients returning from offsite specialty
clinics and procedures. The patients are appropriately referred to specialty care. The referral coordinator ensures that the patients get an appointment in a timely manner. The providers and the coordinator work very well together. The provider calls the specialist if a patient needs to be prioritized.
The patients scheduled for the appointment is reviewed by the Physician leadership as a safety check and to monitor utilization. A project has been initiated to study the reason for offsite visit refusals in order to identify opportunities to reduce refusals.
The care coordination nurse does a good job in tracking the patients coming back from their appointments and ensures that the follow-up recommendations are addressed.
Obstetrics care remains in substantial compliance. Monitor’s Recommendations:
Care coordination nurse to review the chart to ensure that the patients get the needed previsit orders/tests done before their off-site visit. 58. Dental Care Cermak shall ensure that inmates receive adequate dental care, and follow up, in accordance with generally accepted correctional standards of care. Such care should be provided in a timely
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Case: 1:10-cv-02946 Document #: 365 Filed: 12/27/17 Page 49 of 56 PageID #:5652
manner, taking into consideration the acuity of the problem and the inmate’s anticipated length of stay. Dental care shall not be limited to extractions.
a. Cermak shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
Compliance Status: This provision remains in substantial compliance.
Status Update: Received and reviewed on site.
Monitors’ findings: While Cermak census continues to decrease, the total number of dental encounters has
remained stable in some Divisions or has in fact increased in other Divisions over the past 18 months.
The RTU dental clinic is now open and operational. The Monitoring Team met with the Director of Cermak Dental Services and toured the new RTU dental clinic consisting of two dental chairs.
Cermak dental has also operationalized Dentrix since June 2017. This Electronic Dental Record allows for better scheduling and documentation of dental encounters as well as providing automated reporting capabilities thus eliminating the use of manual audits and paper logs. Cermak Dental Services leadership had the opportunity to design the dental encounter templates within Dentrix which will also serve to improve the quality of documentation of dental encounters and the ease of generating meaningful reports.
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Cermak Dental services has created a comprehensive “Oral Health Training” module that is used to educate Cermak healthcare staff (providers and nurses) on identifying and managing common dental issues.
Cermak now has only one vacant dentist positions, the Chief Dentist. This position is currently being recruited. Cermak has already filled the dental assistant position that was vacated during our last visit in April 2017.
Oral surgery needs of the Cermak detainees are being met via Stroger OMFS services. There is good collaboration and communication between Stroger OMFS and Cermak dental services. This is evident based on the average wait time for non-emergent oral surgery for Cermak inmates that continues to decrease while also continuing to compare favorably to the existing wait time for Cook County Hospital ambulatory services patients. The Monitoring Team hopes that the replacement of the currently vacant chief dentist positions will further enhance the dental services program at Cermak and reduce the overall wait times.
Again, the Monitoring Team received from Cermak dental services a comprehensive selfassessment and process improvement plan that included action plan items and audit results for the past 6 months. Included in this document were monthly encounter numbers as well as a breakdown of extractions vs. restorative procedures. Cermak continues to perform a very high percentage of restorations vs. extractions. This has a significant positive impact on the oral health of the inmates at Cook County Jail and the overall oral health of the Cook County residents. Cermak dental now handles all of its own appointments based on the HSR received (all HSR regardless of acuity and all follow up appointments). Some appointments continue to be scheduled through the scheduling center (annual exams, consults, provider referrals, etc.). During our visit, The Monitoring Team identified an issue with the manner by which nursing staff
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handle dental HSR forms. In several cases, there was lack of documentation of a face to face nurse encounter for urgent dental HSR forms (severe pain, swelling, bleeding, etc.). An action plan to address this issue was created before our departure. The action plan aims to streamline the referral process for dental HSR forms similar to those involving mental health issues. Similar to our last visits, the Monitoring Team audited several dental encounters from different Cermak Divisions with regard to:
 Date of actual HSR  Date the HSR was received by dental clinic  Date of dental clinic appointment  Reason for visit (symptomatic vs. asymptomatic)  Documentation regarding face to face nursing encounters when such encounter was
indicated The Monitoring Team elected to look mainly at the “urgent” dental complaints. This decision was based on the fact that while the timeliness for the dental services for routine, priority and annual exams has remained acceptable, the wait time for urgent dental complaints continues to surpass the goal of 3 business days. It is important to note, however, that the overall trend for urgent dental HSR wait time is significantly improved (decreased) since January 2017. Our audit confirmed the overall self-assessment report that was presented to the Monitoring Team by Cermak dental services. This report was based on 100% of all dental encounters over the past six months. The timeliness compliance report for different divisions and acuities was for the most part in compliance with the wait times set according to the revised dental policy:
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a) Emergent

same day

b) Urgent

within 3 business days

c) Priority

within 14 days

d) Routine

within 30 days

e) Annual exam

within 90 days

As mentioned above, the only exception to the timeliness of dental wait times was for inmates

with urgent dental complaints while the overall wait time trend had significantly improved.

Cermak dental continues to strive for a culture of continuous quality improvement with monthly

dental Access to Care and Quality of Care grievances hovering in single digits including zero

Access to Care grievance in October 2017 and zero Quality of Care grievances for the three

consecutive months prior to our visit.

Monitor’s Recommendations:

1. Formulate and submit the action plan regarding the handling of urgent dental HSRs. 2. Monitor the requirement for face to face nurse visits for urgent dental HSRs. 3. Address the issue of wait time for Urgent dental HSR. 4. Continue to expand the dental services with the replacement of the Chief Dentist position.

68. Suicide Prevention Training

a. Cermak shall ensure that the Facility’s suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics:

i. the suicide prevention policy as revised consistent with this Agreed Order;
ii. why facility environments may contribute to suicidal behavior;
iii. potential predisposing factors to suicide; 51

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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 (Serious suicide
attempts are typically considered to be those that either were potentially lifethreatening or that required medical attention); ix. mock demonstrations regarding the proper response to a suicide attempt; and x. The proper use of emergency equipment, including suicide cut-down tools. b. Within 24 months of the effective date of this Agreed Order, CCDOC shall train all CCDOC staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. 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 in accordance with generally accepted professional standards. c. Within 12 months of the effective date of this Agreed Order, Cermak shall train all Cermak staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. 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 in accordance with generally accepted professional standards.
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Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated Monitor’s Findings:
There was one suicide death since our last monitoring visit. This event, however, occurred in a general population inmate with no warning signs. The log for annual training of staff with regard to suicide prevention was reviewed and found to be up to date. Monitor’s Recommendations:
None. 86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 53

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d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
Compliance Status: This provision remains in Substantial Compliance.
Status Update: Received and reviewed.
Monitor’s Findings: Cermak has a quality management plan, and a performance dashboard to track the key
metrics. The information is reviewed by a multidisciplinary team every month during the quality meeting.
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A well-qualified Quality Director has been hired to lead the quality and safety efforts. The director has implemented several best practices in a short time. The fundamental aspects of quality, safety and project management are being implemented. This is essential for a successful program.
Pharmacy department has a well-established quality program. Pharmacy maintains an extensive dashboard to track their performance metrics. New projects have been identified based on the needs of the program. A multidisciplinary meeting has been established to continuously identify and implement best practices.
Several innovative programs are being implemented by the leadership at Cermak. They are developing innovative approaches that can become best practices for other correctional faculties to follow.
CCDOC is participating actively with Cermak and DFM in a jointly established Health Care Quality Improvement Committee. There is good collaboration for improvement efforts. Cermak is participating with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee. The performance metrics are used to track compliance and progress. DFM Cermak is participating with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee Monitor’s Recommendations:
1. Continue to build the quality program through collaboration with all disciplines 2. Share your best practices with other organizations
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 Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 1 of 86 PageID #:5668

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

UNITED STATES OF AMERICA,

)

)

Plaintiff,

)

v.

)

)

COOK COUNTY, ILLINOIS;

)

THOMAS DART, COOK COUNTY

)

SHERIFF (in his official capacity);

)

TONI PRECKWINKLE, COOK COUNTY )

BOARD PRESIDENT (in her official capacity); )

COOK COUNTY BOARD OF

)

COMMISSIONERS (in their official capacity), )

)

Defendants,

)

No. 10 C 2946 Judge Virginia Kendall

Monitor Jeffrey L. Metzner, M.D.’s Report No. 15 November 13-15, 2017

Jeffrey L. Metzner, M.D., P.C. 3300 East First Avenue Suite 590 Denver, CO E-mail: Jeffrey.metzner@ucdenver.edu

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 2 of 86 PageID #:5669
Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 2 of 86
JEFFREY L. METZNER, M.D., P.C. 3300 EAST FIRST AVENUE SUITE 590 DENVER, COLORADO _____ TELEPHONE (303) 355-6842 FACSIMILE (303) 322-2155

MEMORANDUM

TO:
FROM: DATE: RE:

Anthony E. Zecchin, Esq. Cook County State's Attorney's Office 500 Richard J. Daley Center Chicago, Illinois 60610
Paul O’Grady, Esq. Peterson Johnson& Murray 233 South Wacker, 84th Floor Chicago, Illinois 60606
Kerry Dean, Esq. U.S. Department of Justice P.O. Box 66400 Washington, DC 20035-6400
Jeffrey L. Metzner, M.D. December 7, 2017 U.S.A. v Cook County, et al No. 10C2946

I have completed my assessment of the mental health services offered at the Cook County Department of Corrections (CCDOC) through Cermak Health Services of Cook County (CHSCC). I site visited CCDOC from November 13-15, 2017.
Sources of information utilized in compiling this report included the following:
1. review of documents provided in response to my written request for pre-site information, which included the following documents: a. status update to the Agreed Order, b. numerous mental healthcare quality improvement studies,
2. interviews with many inmates in group settings in Division 8 (RTU and the Cermak units) Division 2, Division 6 and Division 10,
3. observation of treatment activities in Divisions 6, 8 and 10,

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 3 of 86
4. information obtained from key administrative and clinical staff that included, but was not limited to, the following persons: a. Linda Follenweider, R.N., N.P. (Chief Operating Officer Hospital Based Services), b. Connie Mennella, M.D. (Chair, Department of Correctional Health Services), c. Nneka Jones Tapia, Psy.D. (First Assistant Executive Director), d. Kenya Key, Psy.D. (Chief of Psychology), e. David Kelner, M.D. (Chief of Psychiatry), f. Jane Gubser (CCDOC Chief of Programs), g. Brian Thomas, M.D. (Associate Chair for Infirmary Care), h. Romica Sillitti, Psy.D., i. Pierre Nunez, Ph.D. (QI coordinator), j. Kimberley Briny, Psy.D. (PSCU Director), k. Brian Waxler, Psy.D. (Male RTU unit director), and l. Gary Kaniuk, Psy.D. (Female RTU director).
As always, I found the staff from CHSCC and CCDOC to be courteous and helpful throughout my five-day site visit.
In this report the term “inmate” will be used in contrast to “detainee” in order to be consistent with the Agreed Order’s terminology, although the vast majority of persons admitted to CCDOC are pre-trial detainees.
Overview
The Cook County Department of Corrections consists of 8 main divisions in a group of buildings covering over 100 acres. The inmate count during November 15, 2017 was 7620.
Reference should be made to Appendix I for a more detailed summary of population and capacity information.
Findings
As per the June 3, 2010 memorandum regarding the June 2, 2010 meeting that included attorneys from the Department of Justice, attorneys and representatives of the Defendants, and the monitors, my findings relevant to the Mental Health Care section of the Agreed Order are summarized in Appendix IV (5-13-10 Agreed Order Mental Health provisions). Consistent with the June 2, 2010 meeting, I have forwarded my input to the medical monitors who have primary responsibility for sections that overlap with various mental health provisions as summarized in the June 3, 2010 memorandum.
Appendix II summarizes the seventeen mental health provisions of the Agreed Order that have been in substantial compliance for at least 18 months, which includes one new provision being in this category. My assessment during this site visit did not raise any concerns that any of these provisions were no longer in substantial compliance. Appendix III summarizes mental health provisions of the Agreed Order monitored by other monitors.

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 4 of 86
Significant accomplishments since the April 2017 site assessment include the following:
1. An additional three provisions have now been in compliance for at least 18 months, which means a total of 20 provisions have been in compliance for at least 18 months.
2. One (1) provision previously in partial compliance is now in substantial compliance, which means there are now five (5) provisions that have been in substantial compliance for less than 18 months.
The provision previously in partial compliance that is now in substantial compliance is as follows:
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility. (6/17)
A major achievement has been accomplished in the context of hiring psychiatrists (currently no vacancies), beginning to hire additional mental health specialists, and decreasing the psychologist’s vacancies. Decreasing the overall mental health staff vacancies has resulted in improved mental health services at every level of care. This assessment is supported by a comprehensive set of quality improvement studies.
Please refer to the executive summary for a brief synopsis of my findings.
The leadership of Kenya Key (Chief Psychologist, Ph.D.), David Kelner, M.D. (Chief Psychiatrist) and Carlos Gomez, Psy.D., Linda Follenweider, R.N., N.P (Chief Operating Officer Hospital Based Services), and Connie Mennella, M.D. remains very impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is very good. The leadership demonstrated by Director Nneka Jones, Psy.D. remains impressive.
Information Requests
Appendix V summarizes my revised document request for my next site assessment scheduled for April 30-May 2, 2018.
Please send me your comments, if any, by December 5, 2017.
Please do not hesitate to contact me if I can answer any further questions.

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 5 of 86 PageID #:5672 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 5 of 86 Sincerely,
Jeffrey L. Metzner, M.D.

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Executive Summary—Fifteenth Monitoring Report (Mental Health Provisions)
Significant accomplishments since the April 2017 site assessment include substantial compliance being achieved with the following provisions:
q. Cermak 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.
r. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility. (6/17)
All provisions of the Agreed Order are now in substantial compliance.
CCDOC has continued to implement a plan for increased out of cell time for all inmates in segregation units as part of the CCDOC plan to gradually increase the recreational time for segregation inmates to at least three to six hours per day. In addition, the custody staff is providing increased correctional rehabilitation programming to a portion of the mental health outpatient level of care caseload inmates.
A major achievement has been accomplished in the context of hiring psychiatrists (currently no vacancies), beginning to hire additional mental health specialists, and decreasing the psychologist’s vacancies. Decreasing the overall mental health staff vacancies has resulted in improved mental health services at every level of care. This assessment is supported by a comprehensive set of quality improvement studies.
The leadership of Kenya Key (Chief Psychologist, Ph.D.), David Kelner, M.D. (Chief Psychiatrist) and Carlos Gomez, Psy.D., Linda Follenweider, R.N., N.P (Chief Operating Officer Hospital Based Services), and Connie Mennella, M.D. remains very impressive. The working relationships between CCDOC and Cermak staffs continues to improve and is very good. The leadership demonstrated by Director Nneka Jones, Psy.D. remains impressive.
An additional three provisions have now been in compliance for at least 18 months, which means a total of 20 provisions have been in compliance for at least 18 months.
One (1) provision previously in partial compliance is now in substantial compliance, which means there are now five (5) provisions that have been in substantial compliance for less than 18 months.
There are no provisions in either partial compliance or non-compliance.
Summary of Compliance Findings
The following provisions were assessed to be in substantial compliance (with the initial date of substantial compliance noted in parenthesis): Bolded provisions indicate that the provisions have been in substantial compliance for more than

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18 months.
59. Assessment and Treatment
a. Results of mental health intake screenings (see provision 45.c, “Intake Screening”) will be reviewed by Qualified Mental Health Staff for appropriate disposition. (6/12)
b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates’ mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs. (10/12)
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate’s medical record. (11/16)
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional. (4/17)
e. Cermak shall ensure that treatment plans adequately address inmates’ serious mental health needs and that the plans contain interventions specifically tailored to the inmates’ diagnoses. (4/17)
f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates’

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serious mental health needs and ensure that psychiatrists see inmates in a timely manner. (11/16)
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defining the various levels of care and identifying the space, staffing, and programming that are appropriate to each identified level of care. (4/17)
h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate. (11/16)
i. Cermak shall provide the designated CCDOC official responsible for inmate disciplinary hearings with a mental health caseload roster listing the inmates currently receiving mental health care. (6/12)
j. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate’s serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate’s mental health status. (10/12)
k. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak’s assessment.
l. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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

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evaluations, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. (11/15)
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year. (6/12)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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. (4/16)
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility. (6/17)
60. Psychotherapeutic Medication Administration
a. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate’s psychotropic medications are clinically justified and documented in the inmate’s medical record.
b. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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

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provide treatment where appropriate. (4/17)
61. Suicide Prevention Policy
a. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
b. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
c. 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. (11/13)
62. Suicide Precautions a. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks. b. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks. c. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff. d. Cermak shall develop and implement policies and procedures for suicide

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precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be

altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances. (11/15)

63.

Cermak shall ensure that Qualified Mental Health Staff assess and interact

with (not just observe) inmates on Suicide Precautions, and document the

assessment and interaction on a daily basis. (11/10)

64. Suicide Risk Assessments a. Cermak 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.

b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality; (5) current medication and diagnosis; and
(6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate’s medical record. (11/13)

65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up. (11/15)

66. Suicide Prevention Policies

a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards. (6/12)

67.

DFM shall ensure that cells designated by CCDOC or Cermak for housing

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suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars. (6/12)
68. Suicide Prevention Training
a. Cermak shall ensure that the Facility’s suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics:
(1) the suicide prevention policy as revised consistent with this Agreed Order;
(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 (Serious
suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools. (12/10)
70. Cermak shall document inmate suicide attempts at the Facility, as defined by the Suicide Prevention Committee’s policies and procedure in accordance with generally accepted correctional standards, in the inmate’s correctional record in CCDOC’s new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement. (6/12)
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each develop and implement policies to address and correct deficiencies that are uncovered during the course of quality management

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activities, including monitoring corrective actions over time to ensure sustained resolution, for each of the provisions of this Agreed Order applicable to that Defendant. (11/15)
Appendix I

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Sheriff's Daily Report 4/10/2017

TOTAL MALE AND FEMALE Jail Population Community Corrections

Under the Custody of the Sheriff

Jail Population
TOTAL MALE AND FEMALE Division 2, Division 3 Annex, Division 6, Cermak, Division 08 RTU, Division 9, Division 10, Division 11 - Male Population Division 4, Cermak, Division 08 RTU - Female Popu lation Division 15 - Outside Counties Division 15 - Hospital
Court-Ordered Programming Within Jail Custody
Division 16 - VRIC (Court Ordered) - Male Population Division 3 Annex, Division 2, Division 6, Division 08 RTU - PRC (Court Ordered Drug Treatment Program) - Male Population Division 4 - Women's Residential (Court Ordered Drug Treatment Program)

Community Corrections Population
TOTAL MALE AND FEMALE Electronic Monitoring (Court Ordered) Men Women M.O.M.s Program (Court Ordered) VRIC Post Release (Court Ordered)

9,811 7,620 2,191
7,620 6,794
481 103 26
22 141
53
2,191
1,930 245 0 16

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Cook County Department of Corrections Executive Director's Log

Monday, April 10, 2017

Prepared By: F. Khan

Totals:

7,620 100%

Male

7,086 93%

Female

534

7%

Male Female

Total

No Place Capacity
To Stay

Div 1

0

-

0 1,250

0

Div 2

1,758

- 1,758 1,960

64

Div 3

0

-

0 360

0

3 Annex

481

- 481 768

18

Cermak

120

17 137 148

6

Div 4

- 301 301 552

5

Div 5

0

-

0 992

0

Div 6

904

- 904 992

12

Div 08

646 163 809 979

40

Div 9

812

- 812 1,066

0

Div 10

724

- 724 768

7

Div 11

1,490

- 1,490 1,536

4

Div 17 W. Residential

-

53

53 152

0

Div 15 - HP

26

-

26

-

2

VRIC In Camp

22

-

22

-

0

Outlying Counties

103

- 103

-

0

Totals:

7,086 534 7,620 11,523 158

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Sheriff's Daily Report 4/10/2017

TOTAL MALE AND FEMALE Jail Population Community Corrections

Under the Custody of the Sheriff

9,811 7,620 2,191

26 0.3% 103 1.4%
481 6.3%

53

141

0.7%

1.9%

22 0.3%

6,794 89.2%

Jail Population
Behind the Walls
Division 2, Division 3 Annex, Division 6, Cermak, Division 08 RTU, Division 9, Division 10, Division 11 - Male Population Division 4, Cermak, Division 08 RTU Female Population Division 15 - Outside Counties
Division 15 - Hospital
Court-Ordered Programming within Jail Custody
Division 4 - Women's Residential (Court Ordered Drug Treatment Program) Division 3 Annex, Division 2, Division 6, Division 08 RTU - PRC (Court Ordered Drug Treatment Program) - Male Population Division 16 - VRIC (Court Ordered) - Male Population

Q. What does Behind the Walls mean?

A. The behind the walls jail population is physically housed under the Sheriff's custody 24 hours a day/7 days a week. This includes all the populations listed on the key above and pie chart to the left - Divisional populations male & female, Outside Counties, Hospital, PRC, Women's Residential, & VRIC. Detainees in court-ordered treatment programs (PRC, Women's Residential, VRIC) are housed at CCDOC 24 hours a day/7 days week.

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59. Assessment and Treatment
a. Results of mental health intake screenings (see provision 45.c, “Intake Screening”) will be reviewed by Qualified Mental Health Staff for appropriate disposition.
Compliance Assessment: Substantial compliance (since June 2012).
b. Cermak shall develop and implement policies and procedures to assess inmates with mental illness; and to evaluate inmates’ mental health needs. Said policies shall include definitions of emergent, urgent, and routine mental health needs, as well as timeframes for the provision of services for each category of mental health needs.
Assessment: Substantial compliance (since October 2012)
c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate’s medical record.
Compliance Assessment: Substantial Compliance (since 11/16)
f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates’ serious mental health needs and ensure that psychiatrists see inmates in a timely manner.
Compliance Assessment: Substantial compliance (since 11/16) h. Inmates shall have access to appropriate infirmary psychiatric care when

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clinically appropriate.
Compliance Assessment: Substantial compliance (11/16)
k. Cermak shall provide the designated CCDOC official responsible for inmate disciplinary hearings with a mental health caseload roster listing the inmates currently receiving mental health care.
Assessment: Substantial compliance (since June 2012)
l. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate’s serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate’s mental health status.
Assessment: Substantial compliance continues (since October 2012).
m. In the case of mentally ill inmates in segregation, CCDOC shall consult with Cermak to determine whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on Cermak’s assessment.
n. Cermak shall ensure that 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 or by Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, in order to assess the serious mental health needs of inmates in segregation. Inmates who are placed in segregation shall be evaluated within 24 hours of placement and thereafter regularly evaluated by a Qualified Mental Health Professional, or by a Qualified Mental Health Staff with appropriate, on-site supervision 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, Cermak shall provide CCDOC with its recommendation regarding whether continued segregation is appropriate or whether the inmate would be appropriate for graduated alternative based on the assessment of the Qualified Mental Health Professional, or Qualified Mental
Health Staff with appropriate, on-site supervision by a Qualified Mental Health

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Professional.
Compliance Assessment: Substantial compliance (11/15)
m. Cermak 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. Cermak shall create such a log within six months of the date this Agreed Order is executed. 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 medical records shall contain current and accurate information regarding any medication changes ordered in at least the past year.
Compliance Assessment: Substantial compliance (since June 2012)
n. Cermak shall ensure that a psychiatrist, physician or licensed clinical psychologist conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. An appropriately credentialed registered nurse may conduct the in-person evaluation of an inmate prior to a seclusion or restraint order that is limited to two hours in duration. 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.
Compliance Assessment: Substantial compliance (since 4/16)
61. Suicide Prevention Policy
d. CCDOC shall participate with Cermak in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.
e. Cermak shall participate with CCDOC in a jointly established Suicide Prevention Committee charged with developing policies and procedures to ensure the appropriate management of suicidal inmates and with implementing and monitoring a suicide prevention program in accordance with generally accepted correctional standards of care.

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f. 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.
Compliance Assessment: Substantial compliance (11/13)
62. Suicide Precautions
e. CCDOC shall ensure that, where suicide prevention procedures established jointly with Cermak involve correctional personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), correctional personnel perform and document their monitoring and checks.
f. Cermak shall ensure that, where suicide prevention procedures established jointly with CCDOC involve health care personnel for constant direct supervision of actively suicidal inmates or close supervision of special needs inmates with lower levels of risk (e.g., 15 minute checks), health care personnel perform and document their monitoring and checks.
g. CCDOC shall ensure that when an inmate is identified as suicidal, the inmate shall be searched and monitored with constant direct supervision until the inmate is transferred to appropriate Cermak staff.
h. Cermak shall develop and implement policies and procedures for suicide precautions that will set forth the conditions of the watch, including but not limited to allowable clothing, property, and utensils, in accordance with generally accepted correctional standards of care. These conditions shall be altered only on the written instruction of a Qualified Mental Health Professional, except under emergency circumstances.
Compliance Assessment: Substantial compliance (11/15)

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63. Cermak shall ensure that Qualified Mental Health Staff assess and interact with (not just observe) inmates on Suicide Precautions, and document the assessment and interaction on a daily basis.
Compliance Assessment: Substantial compliance (since November 2010)
64. Suicide Risk Assessments
a. Cermak 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.
b. Cermak shall ensure that the risk assessment shall include the following: (1) description of the antecedent events and precipitating factors; (2) mental status examination; (3) previous psychiatric and suicide risk history; (4) level of lethality; (5) current medication and diagnosis; and (6) recommendations or treatment plan. Findings from the risk assessment shall be documented on both the assessment form and in the inmate’s medical record. (11/13)
65. Cermak shall ensure that inmates will only be removed from Suicide Precautions after a suicide risk assessment has been performed and approved by a Qualified Mental Health Professional, in consultation with a psychiatrist. A Qualified Mental Health Professional shall write appropriate discharge orders, including treatment recommendations and required mental health follow-up.
Compliance Assessment: Substantial compliance (11/15)
66. Suicide Prevention Policies
a. CCDOC shall ensure that suicide prevention policies established jointly with Cermak include procedures to ensure the safe housing and supervision of inmates based on the acuity of their mental health needs, in accordance with generally accepted correctional standards.
b. Cermak shall ensure that suicide prevention policies established jointly with CCDOC include procedures to ensure the safe housing and supervision of inmates based on the

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acuity of their mental health needs, in accordance with generally accepted correctional standards.
Compliance Assessment: Substantial compliance (since June 2012)
67. DFM shall ensure that cells designated by CCDOC or Cermak for housing suicidal inmates shall be retrofitted to render them suicide-resistant (e.g., elimination of protrusive shower heads, unshielded lighting or electrical sockets). Inmates known to be suicidal shall not be housed in cells with exposed bars.
Compliance Assessment: Substantial compliance (since June 2012)
68. Suicide Prevention Training
b. Cermak shall ensure that the Facility’s suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics: (1) the suicide prevention policy as revised consistent with this Agreed Order; (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 (Serious suicide attempts are typically considered to be those that either were potentially life-threatening or that required medical attention); (9) mock demonstrations regarding the proper response to a suicide attempt; and (10) the proper use of emergency equipment, including suicide cut-down tools.
Compliance Assessment: Substantial compliance (since December 2010)
70. Cermak shall document inmate suicide attempts at the Facility, as defined by the Suicide Prevention Committee’s policies and procedure in accordance with generally accepted correctional standards, in the inmate’s correctional record in CCDOC’s new Jail Management System, in order to ensure that both correctional and health care staff will be aware at future intakes of past suicide attempts, if an inmate with a history of suicide attempts is admitted to the Facility again in the future. Cermak will begin to document this information within six months after execution of this Agreement.

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Compliance Assessment: Substantial compliance (since June 2012)
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
86. Quality Management and Performance Measurement
a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant.
b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant.
Compliance Assessment: Substantial compliance (11/15)

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Appendix III

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Mental health provisions of the Agreed Order monitored by other monitors
H. QUALITY MANAGEMENT AND PERFORMANCE MEASUREMENT
c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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.
e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation.
Compliance Assessment: Refer to the report by Dr. Shansky (initially found to be in substantial compliance during 2011 and again during 2013)
69. CCDOC shall ensure that security staff posts will be equipped, as appropriate, with readily available, safely secured, suicide cut-down tools.
Compliance Assessment: Refer to the report by Susan McCampbell.

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Appendix IV

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P: AGREED ORDER

D. MENTAL HEALTH CARE

59. Assessment and Treatment

c. Cermak shall ensure that any inmate who screens positively for mental illness or suicidal ideation during the intake screening process, through a mental health assessment, or who is otherwise referred for mental health services, receives a clinically appropriate mental health evaluation in a timely manner, based on emergent, urgent, and routine mental health needs, from a Qualified Mental Health Professional, or Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional. Such mental health evaluation shall include a recorded diagnosis section on Axis I, II, and III, using the DSM-IV-TR, or subsequent Diagnostic and Statistical Manual of the American Psychiatric Association. If a Qualified Mental Health Professional, or a Qualified Mental Health Staff with appropriate, on-site supervision by a Qualified Mental Health Professional, finds a serious mental illness, they shall refer the inmate for appropriate treatment. Cermak shall request and 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 of the assessment. Cermak shall adequately document the mental health evaluation in the inmate’s medical record.

Compliance Assessment: Substantial Compliance (11/16)

Factual Findings:

November 2017 Cermak Status Update

October 2017

Total Jail Population as of 10/06/2017: 7,128

P2-Outpatient Mental Health

1633- 22% (of total)

P3-Intermediate Mental Health 385-5.4% (of total)

P4-Psych. Special Care Units

73-1.02% (of total)

Mental Health Case Caseload 2,091 (29%)

78% (of MH load) 18.4% (of MH load) 3.4% (of MH load)

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April 2017

Total Jail Population as of 3/23/2017: 7,598

P2-Outpatient Mental Health

1679 22 % (of total)

P3-Intermediate Mental Health 394 5.1% (of total)

P4-Psych. Special Care Units

74 0.97% (of total)

Mental Health Case Caseload 2,147 (29%)

78% (of MH load) 18.35% (of MH load) 3.4% (of MH load)

The number of patients on Mental Health Caseload has not significantly changed Furthermore, the proportion of detainees in Psychiatric Special Care Units, Intermediate Level of Care, and Outpatient Level of Care– P4, P3 and P2, respectively, has remained constant. Various diversion programs have not, seemingly, diminished the proportion of the seriously mentally ill and the violent offenders.

All Providers, Psychologists, MSW and MHS continue to use their personalized access to the Jail Data Link database allowing them to source data about previous admissions to municipal and state institutions receiving federal grants or directly administered by the State of IL. All Providers, Psychologists, MSW and MHS have personalized access to the Jail Management System (CCOMS) allowing them to review charges, legal and disciplinary history in real time. All the WYSE terminals and desktops that Cermak utilizes across the compound (including RCDC) permit CCOMS access.

The process to secure Releases of Information to obtain community treatment records remains an area of important focus. Mental health staff are routinely seeking releases of information for community providers during the intake process and post intake when needed. Cermak present process has been modified:

1. Cermak staff utilizes an updated ROI form (can also be accessed from the Mental Health folder in the intranet—under “Frequently Used Forms” or “RCDC Specific Information”). The new form has the MH fax number (instead of the medical records fax).
2. The request is faxed to community providers using the list of MH providers that our patients report most frequently (the list can also be accessed via the intranet under RCDC Specific Information)
3. The original ROI form and the fax confirmation are placed in the “Community ROI forms” inbox located in the MHS administration, the RCDC Unit Director retrieves them for review of completeness, then provides them to the department Administrative Assistant.
4. Administrative Assistant logs the date the request is faxed out. 5. Collateral records are faxed to the MHS fax; AA logs receipt and distributes the records
to Providers deployed in the patient’s clinical area.

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6. Providers review records and enter a brief summary in EMR. Then medical records are submitted to HIMD
During the 3-month period between July 1, 2017 and September 30, 2017, Intake/RCDC staff executed 382 releases to obtain records from community mental health providers. This equates to an average of four (4.2) per day. The length of time from the date the release was executed to the date the records were received ranged from the same day (0 days) to 36 days, with an average of 9.5 days for receipt of the records. Dr. Butler assumed leadership over the RCDC area as a Unit Director. During RCDC group supervisions case conferences, including peer review, are conducted to address the quality of secondary mental health assessments and identify outliers among staff. The main focus is to discuss quality of dispositions and risk assessments. Dr. Butler conducted an audit and analysis of assessments and dispositions made by the Intake QMHP staff. The double blind audit of intake mental health assessments reflected a high level of concurrence between the supervisor and individual assessors’ dispositions. See PDF Appendix.
On average more than 47% of female detainees and approximately 26% of male detainees are referred for secondary mental health assessment from the initial health screening. Additionally, appropriate identification of mental illness and placement on the mental health caseload at intake is consistently more than 91%. Please see Excel Appendix for Intake Referral data.
The Mental Health team in RCDC continues to be dedicated to working collaboratively with the Initial Intake Screeners, CCDOC staff, and Medical staff to ensure thorough and efficient assessment of the patients we serve. Particular focus has been given to ongoing improvement in the quality of the charting, appropriate dispositioning of patients, processing Releases of Information (ROIs) in a timely manner and addressing staffing and coverage needs.
Coverage for the RCDC has largely been supported by assignment of overtime staff. This need will decrease with the hiring of new MHS staff for this area, with one addition to the team taking place since the last site visit. Additionally, Dr. Mary-Ellen Butler accepted the RCDC Unit Director position in March of 2017; thus, there is now a fulltime supervisor onsite in the evenings to provide onsite direct supervision of the workflow in RCDC. To this end, there has been an increased focus on the quality of the charting for the Mental Health Assessments (MHAs) conducted by Mental Health Specialists in RCDC and accuracy in P-level disposition. Dr. Butler routinely audits the charting and provides feedback to RCDC staff. Onsite supervision allows for real time consultation and reinforces the expectation that charting is to provide a comprehensive snapshot of the patient’s current functioning. Dr. Butler meets with RCDC mental health staff monthly for individual supervision and weekly for group supervision.

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Dr. Butler ensures that all referrals for Intake Mental Health Assessments are completed timely by closely monitoring the queue for patients that may have had to bypass the routine intake processes due to acute mental and/or medical distress. These patients are sent directly to Cermak Urgent care and will have the assessment completed there after stabilization of acute presentation. Periodically, mental health assessments are completed in the patients’ assigned housing unit. The RCDC Unit Director shares the information from the queue with the divisional Unit Directors daily so that they are able to assign divisional Mental Health Specialist staff to complete the assessments in a timely manner.

The Mental Health team in RCDC also continues to work in concert with Medical and Intake staff to ensure fluidity and process improvement in RCDC. When patients are may not forthcoming with providing initial intake screening staff accurate and/or thorough information about their psychiatric history the potential for false negatives on the screening increases. The previous cutoff threshold for an automatic referral for a secondary mental health assessment, 13 was formally lowered to 1. This results in any patient answering affirmatively to any mental health related question on the initial screen being referred for a secondary mental health assessment. Furthermore, Dr. Butler and the Nurse Manager over Intake, Nurse Reed, are in constant communication to assure that the staff are provided with appropriate guidance to maintain efficient and effective work flow. An Intake work group was also convened to provide a forum for discussion related to ongoing process improvements.

Psychiatry Face to Face visits:

Psychiatrists Physician Assistants

June 2133 589

July 2112 485

August 2578 364

September 2540 479

Dr. Kelner reviewed psychiatry referrals originating in the intake process as per below (also see Excel Appendix for data):

Psychiatry Emergent Intake Referrals:

Status

Seen

Not Seen

Month

#

%

2) Over 4hrs

4) No Note

#

#

% #

%

2017_03 129 95.56% 4 2.96% 2 1.48%

6

Total
%

4.44%

135

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2017_04 154 97.47% 2 1.27% 2 1.27%

4

2.53%

158

2017_05 141 96.58% 3 2.05% 2 1.37%

5

3.42%

146

2017_06 164 96.47% 6 3.53%

0.00%

6

3.53%

170

2017_07 147 98.00% 3 2.00%

0.00%

3

2.00%

150

2017_08 115 95.04% 5 4.13% 1 0.83%

6

4.96%

121

2017_09 115 91.27% 5 4.03% 4 3.23%

9

7.26%

124

Charts were audited for August. In August 2017 95.04% detainees were seen within 4 hours (in keeping with the timeframe) when referred with Psychiatry Emergent Referral. Out of the 6- 4.96% that were not seen timely, 5- 4.13% were still seen in RCDC (Intake) but outside of the 4 hour timeframe. 1- 0.83% was not seen in Intake, as they were either fast tracked, given acuity, prior to Psychiatrists being able to see them, to PSCU and MSCU/detoxification units. Additionally, and in keeping with prior data, a small proportion of that cohort had orders for Psychiatry Intake placed in EMR when it was assumed by MHS that Psychiatry would be present on site, but then, due to call offs Psychiatrists did not show up and original orders were not cancelled.

Psychiatry Urgent Intake Referrals:

Urgent(P4)
3_2017 4_2017 5_2017 6_2017 7_2017 8_2017 9_2017

1) Within 24 hrs

95

90.%

69

91.%

98

91.%

95

92.%

83

92.%

68

94.%

99

90.%

2) Over 24 hrs

8

8.%

6

8.%

8

7.%

6

6.%

6

7.%

2

3.%

7

6.%

No Note

3

3.%

1

1.%

2

2.%

2

2.%

1

1.%

2

3.%

4

4.%

Total 106 76 108 103 90 72 110

Charts were audit for August. In August 2017 94% of detainees referred for Urgent Psychiatry Referral were seen within 24 hours (in keeping with the timeframe). 3 % of detainees that were not seen within the next 24 hours were mostly detainees that fell into one of the following categories: a. Admitted on Fridays and weekends. Psychiatrists saw them later in the day and detainees who were assigned P4 level (were “slated” for PSCU admission) and then were diverted to MSCU and detoxification Units, thus delaying their contact with Psychiatry. Daily PSCU Mental Health Level of Care Tracker continues to allow Psychiatric Providers review lists of patients with P-alerts in MSCU( identification of these detainees with P4 alerts admitted from RCDC to MSCU is critical since there are no scheduling templates in PSCU and MSCU). b. Transferred to John Stroger Hospital (and other hospitals) due to medical problems and detoxification protocols requiring inpatient care and observation and could not be seen within 24 hours by Cermak Psychiatrists. An internal system of notifications between JSH Consultation and

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Liaison Psychiatrists and Cermak Providers serves to alert JSH C/L Service to CCDOC detainees’ arrival. Dr. Thomas has taken over consultative services in MSCU.

Psychiatry Routine Intake Referrals:

Routine( P2/P3)
3_2017 4_2017 5_2017 6_2017 7_2017 8_2017 9_2017

1) Within 14 days
370 62.% 371 64.% 425 60.% 334 53.% 333 53.% 366 59.% 362 56.%

2) Between 15-21 days 15 3.% 7 1.% 25 4.% 26 4.% 31 5.% 24 4.% 17 3.%

3) Between 22-30 days 2 0.% 6 1.% 14 2.% 13 2.% 6 1.% 8 1.% 3 0.%

4) D/C within 15 days
176 29.% 154 26.% 181 26.% 188 30.% 206 33.% 187 30.% 192 30.%

5) D/C over 15 days without
Note 28 5.% 36 6.% 33 5.% 46 7.% 28 4.% 18 3.% 18 3.%

6) No Note 9 2.% 10 2.% 25 4.% 21 3.% 20 3.% 21 3.% 53 8.%

Total
600 584 703 628 624 624 645

Charts were audited for August and September. In August 2017 366 (59%) detainees referred for Routine Psychiatry referral, and remaining on campus, were seen within 14 days (in keeping with the timeframe). 187(30%) of detainees were discharged within 14 days and were not able to be seen by Psychiatry. 24 (4%) detainees who were seen by Psychiatry outside of the timeframe were seen between 15th and but under 22nd day. Chart audit for the cases that did not have Providers’ notes in EMR in August 2017 revealed that, when all the false positives and discharges from custody are subtracted, the actual number of detainees not seen as Routine Psychiatry Referrals was much smaller.

Count

August 2017

30 25 20 15 10
5 0
SPIDOC/EM/ SPFF/Dischar ge/extraditio
n

Count

26

Accumulation 66.67%

Scheduling Issue
7 84.62%

False Postive/Seen witin Range
3 92.31%

No Note
1 94.87%

PT not on Case
Load/No Plevel
1
97.44%

No Show

9100.00.00%0% 7800..0000%% 5600..0000%% 3400..0000%% 1200..0000%% 0.00%

1 100.00%

Thus, out of 39 patients who were captured by Cerner as not having notes within the 14 timeframe, 26 were not on the compound by the end of the timeframe period, 7 missed their appointments

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related to various scheduling issues mostly related to schedulers scheduling detainees outside of timeframe ( see the corresponding chart above), and other various reasons. The resultant calculation is that 90.8% of Routine Referrals in August had notes written within the appropriate timeframe.
In September 2017 362 (56%) detainees referred for Routine Psychiatry referral, and remaining on campus, were seen within 14 days (in keeping with the timeframe). 192 (30%) of detainees were discharged within 14 days and were not able to be seen by Psychiatry. 17 (3%) detainees who were seen by Psychiatry outside of the timeframe were seen between 15th and but under 22nd day. Further audit of 71 charts of those who did not have notes in their charts within the required timeframe revealed the following:

Count

September 2017

45

40

35

30

25

20

15

10

5

0

SPIDOC/E M/SPFF/Di scharge/ex tradition

Scheduling Issue

Movement /Lock Down

Count

39

19

6

Accumulation 55.71% 82.86% 91.43%

Refused
2 94.29%

PT not on Case
Load/No Plevel
2
97.14%

No Show
1 98.57%

No Note
1 100.00%

9100.00.00%0% 7800..0000%% 5600..0000%% 40.00% 2300..0000%% 01.00.00%0%

The data indicates that, when false positives (discharges, lockdowns, court movements, refusals, not on caseload, no shows) are factored in, the rate of compliance with the timeframe is 93%. Scheduling process continues to contribute to missed assessments. Additionally, in August /September 2017 Cook County has changed the bond system. A set of new rules was introduced that mandates Bond Court Judges to set bail for felonious offenders in the amount that they can afford, that is a more in depth view of detainees’ financial assets accompanies detainees when they go to their bond court hearing. Similar rules are to be introduced for misdemeanants in the fall of 2017. The said process has led to an increase in releases from custody to various court supervised diversion programs, including electronic monitoring.
Two major recurring trends have been identified as a result of 110 chart audit/review for August/September 2017:

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 Cerner continues to capture many IDOC transfers (most of them were parole holds upon admission to CCDOC)/Electronic Monitoring releases/Furloughs/15SFFP/, and extraditions as being physically on campus and, therefore, they are seen as “never having contacts with Psychiatry”.
 Scheduling related errors remain an area of vulnerability. COO took over the scheduling Department. The new system increases accountability and yet the transition between the old system and the new centralized process affected the numbers to some extent. The new process relies on real time frequent updates going to clinical areas from the centralized computer generated data bank regarding patient movement to the clinics across the compound. Additional information is available in the PDF appendix.
Detainees seen between 15 and 21st
day- 4% and 3%
Compliance rates 90.8% and 93%
Figure 1Compliance rates with Routine Psychiatry Assessments in August/September 2017
Daily reports for P Level detainees returning on the compound after hospital stays (15HP) are automatically generated, translated into an automated report, and become available to staff.
Outlying County returns reenter the compound after undergoing a Medical Mini screening as well as MH evaluation in RCDC. Their appointments with Psychiatry are rescheduled by a MHS. Medications are restarted once their housing is determined.
CCDOC continues to utilize the CCOMS DOC Intake Referral to Mental Health alerts that crosses the interface with Cerner EMR and serves to facilitate referral of SMI detainees flagged by CCSO staff during the booking process in RCDC.

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November 2017 Metzner assessment: Substantial compliance continues. The percentage of the total population on the mental health caseload as well as the percentages specific to the various levels of mental health care being used are consistent with national averages. The quality improvement studies relevant to the mental health screening process continues to be a very useful supervisory/peer review process as do the other audits relevant to this provision. Compliance with urgent and emergent psychiatric referral timelines continues to be maintained as does compliance with obtaining release of information consent forms when clinically appropriate.
Recommendations: Continue to self-monitor.
d. Cermak shall ensure clinically appropriate and timely treatment for inmates, whose assessments reveal serious mental illness or serious mental health needs, including timely and regularly scheduled visits with Qualified Mental Health Professionals or with Qualified Mental Health Staff, with appropriate, on-site supervision by a Qualified Mental Health Professional.
Compliance Assessment: Substantial compliance (4/17)
November 2017 Cermak Status Update
COMPOUND HOUSING PLAN BY MENTAL HEALTH LEVELS OF CARE (as of October 2017)
 Cermak- P4 (Psychiatric Special Care Unit)- 2N acute male, 2W-acute and chronic female, 2S/2SE- male subacute, 2E- male chronic, P4 can also be housed on the third floor in Medical Special Care Unit under special circumstances. Housing on 3S for Mental Health reasons requires transfer orders from PCC/ Dr. Mennella. Patients with M4 and P4 can be housed on the Medical Special Care unit based on interdisciplinary decision.
 Division II: MALE MENTAL HEALTH HOUSING  Dorm 2: Mental Health Outpatient P2; **if any Mental Health Intermediates (P3) are placed there, MH staff works on transferring them to RTU; CCDOC houses detainees that attend MHTC (Mental Health Transition Center) in Division II Dorm 2  Dorm 1: NO MENTAL HEALTH HOUSING  Dorm 3: NO MENTAL HEALTH HOUSING  Dorm 4: NO MENTAL HEALTH HOUSING
 Division IV FEMALE MENTAL HEALTH HOUSING o Mental Health Outpatient P2- 1st and 2ndfloors
 Division V: NO MENTAL HEALTH HOUSING  Division VI: MALE MENTAL HEALTH HOUSING

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o Westcare tier –2C (substance abuse, court ordered treatment program), Mental Health Outpatient P2
o Protective Custody: 1K, 1J and 1N o Therapeutic Tier –P2 1K; detainees area vetted for admission by MH ( non P3)  Division VIII RTU: MENTAL HEALTH HOUSING o 5th floor Females
 Mental Health Intermediates P3 (tiers B, F) Mental Health Outpatients P2 and DETOX (all other tiers), Pre/postnatal
 SMU (tier A) Protective Custody (tier E) (restrictive housing require mental health clearance prior to placement/within 24 h)
o 4th floor Males  Mental Health Intermediates P3 (all tiers)  SMU (tier A) Protective Custody (tier E)  Mental Health Intermediates P3 (restrictive housing require mental health clearance prior to placement/within 24 h)
o 3rd floor Males  Medical Intermediate M3s (may also be P2s) with overflow Mental Health Intermediate P3s
o 2nd floor Males  Mental Health Intermediate Overflow P3  Intensive Management Unit (tier 2A)-P3  DETOX
 Division IX: MALE MENTAL HEALTH HOUSING  Protective Custody (Tiers 3G, 3H )
 If conditions of confinement are more restrictive than GP, Mental Health Outpatient P2 require mental health clearance prior to placement/within 24h **No Mental Health Intermediates P3 should be cleared by mental health to transfer to PC in Division IX; they should only be cleared for SMU in Division VIII RTU
 SMU- non-administrative SMU (Tier 1E, 1G, 1H; 1F- enhanced security tier); 1G houses only those detainees who have P2 alerts.  Mental Health Outpatient P2 (require mental health clearance prior to placement/within 24h) **No Mental Health Intermediates P3 should be cleared by mental health to transfer to SMU in Division IX; they should only be cleared for SMU in Division VIII - RTU
 General Population (all other tiers in the division)  Mental Health Outpatient P2
 Division X: MALE MENTAL HEALTH HOUSING: Mental Health Outpatient P2 **if any Mental Health Intermediates (P3) are placed there, MH staff works on transferring them to RTU o Protective Custody -1C (meeting criteria of SMU housing) and 2C  **No Mental Health Intermediates should be cleared by mental health to transfer to SMU/PC in Division X; they should only be cleared for SMU in Division VIII RTU

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 2B- Therapeutic Tier ( non P3)  Division XI: NO MENTAL HEALTH HOUSING  Division XVI (Boot Camp): NO MENTAL HEALTH HOUSING; detainees on dose by
dose medications cannot be in Boot Camp (and that excludes any patient on psychotropics)
Compound Wide Psychiatry Updates
Cermak
Dr. Brian Thomas (Associate Chair for Infirmary Care) assumed supervisory authority over PSCU in August 2017. Psychiatric coverage of the Psychiatric Special Care Units has been largely unchanged: 2N is covered by 3 Psychiatrists and 1 Psychiatric PA (Balawender). 2W covered by 2 Psychiatrists. 2S/2SE is covered by two Psychiatrists. 2E is covered by on Psychiatrists. All the Psychiatrists combine PSCU coverage with some divisional clinics. 5.8 FTE’s (included is relief factor) are assigned to PSCU and provision of psychiatric consultative services in MSCU. Section 59f. contains detailed descriptions of Psychiatric allocations within the PSC Units. Please see PDF Appendix for QI related to frequency of contact of PSCU patients.
Residential Treatment Unit
Average daily Population is 400 P3’s and 190 P2’s. Average SMU/IMU population with census18 and 6 respectively. Of note, that there are no P3 patients housed outside of RTU and the need to create more P3 tiers to accommodate P3 overflow previously housed in Division X has significantly diminished. RTU males are housed on the second, third and fourth floor of the RTU building. RTU females are housed on the fifth floor of the building. The number of detainees with P3 alert averages 20 for the second and third floors of RTU. 1FTE is assigned to P2 /SMU/IMU. 5.2FTE’s are assigned to provide services to P3’s in RTU.
Psychiatric services in Male RTU have been expanded. Staffing levels in this high priority area (RTU) remain a focus for Psychiatry Administration. Present Psychiatric allocations in RTU are outlined in the staffing section of this Status Update report, see 59f.
Psychiatric allocations absorb Special Management Units with average daily census 18 (mixed Classification Units within the building housing detainees with various combinations of P3,P2, and M- Alerts) + Intensive Management Unit with average daily census 6 (housing SMI detainees with P3 Level of Care).

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Division II Dorm 2.
Two Psychiatrists provide Psychiatric services in this division that houses minimum and medium security P2 detainees. One Provider continues to provide Telepsychiatric services on full time basis. The other Provider is on site. Patient population is 378.
Division IV.
Psychiatric services are provided by one Psychiatric Physician Assistant. He continues to exceed expectations and provides reliable coverage to minimum, medium and maximum security P2 female detainees. There are no P3 detainees left in Division IV. Physician assistants are assigned to lower acuity areas. Patient population is 134.
Division VI.
Psychiatric services are provided by Two Psychiatrists. Division VI has experienced expansions and recent contraction of medium and minimum security P2 detainees. There are no P3 detainees are housed in this division. Telepsychiatric services in Division VI have been eliminated and presently Psychiatry coverage is provided only by on site Providers. Patient population is 216.
Division IX.
Psychiatric services are provided by one onsite Psychiatrist. There are no P3 detainees in this division. Division IX continues to be a very high acuity area with four SMU units and 4 Protective Custody Units accompanied with concentrated levels of institutionally disruptive predominantly maximum security P2 detainees. Institutional challenges related to the nature of SMU units and maximum security predictably lessen access to mental health services. Frequent rotation of Division IX Providers will be carried out (annually) in order to prevent burn out. Patient population is 311.
Division X.
Psychiatric services to P2 detainees are provided by two on site Psychiatrists. Division X houses no P3 detainees. Telepsychiatric services have been eliminated from this division. Presently additional clinical space is being modified in the basement of Division X to accommodate recent expansion of Psychiatry clinics. Patient population 383.
Cermak Basement Clinic continues to provide services to detainees from divisions XI and Division II Dorms 1, 3, 4. Patient movement to this clinical location has been declining since the

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introduction of a new policy which prescribes to transfer detainees to Mental Health Housing and give them a corresponding P level alert after triage by MHS, when it is decided that these detainees need a consultation with Psychiatry.
FTE allocations for P2 detainees are 5.1 Physician /patient ratio for maximum security detainees is 1:291 Physician /patient ration for minimum security detainees is 1:284 Medium security detainees are absorbed in these calculations.
Women’s Services (RTU-5th Floor & Div. 4) Updates
Cermak Health Services of Cook County provides mental health services to the mix of P3, P2, and SMU populations on the 5th floor of RTU and Division Four. All of the pregnant females in the institution are housed on 5-C in the RTU. Dr. Kaniuk is the Unit Director of RTU-5 and Division Four. In addition to psychiatry and psychology staff, there are 15 employees assigned to the two female divisions, including mental health specialists, medical social workers, and an expressive therapist.
Division Four houses P-2 detainees in a celled setting. There are 23 (as of October 9, 2017) P-2 detainees enrolled in the THRIVE (Women’s Residential) Program (court ordered), which is facilitated by the CCSO’s Office of Programmatic Services and the Office of Mental Health and Advocacy. There is one P-3 detainee (as of October 9, 2017) being transferred from RTU on a daily basis to attend group in the THRIVE Program. Cermak and CCSO staff continue to work together to address the challenges of sharing the same caseload. Mutual roles and expectations are in the process of being defined. Agreements have been confirmed in terms of access to DHCRF process, along with routine and emergent services provided by Cermak Health Services staff. Staff in both agencies continue to work to minimize confusion regarding who is providing linkage-reentry services. One such solution has been the introduction of a “mental health linkage” alert that Cermak medical social work staff enter into the EMR which populates to the CCOMS system making CCSO staff aware that the patient is working with Cermak clinical staff to develop a discharge plan. In general, mental health staff have a good working relationship with security in both RTU-5 and Division Four. Supt. Yoksoulian and Supt. Baker are both supportive of clinical programming services and open to the concerns of mental health. There
are weekly divisional meetings that serve as a venue to maintain open communication, collaboration, and problem-solving for the entire multidisciplinary team.
Division 4 - There are approximately 140, P-2 patients in Division Four, as well as general population and M-2 detainees. Division Four is staffed with two mental health specialists who

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complete mental health clinic (Monday through Thursday mornings) and evaluations (IAHI and HSRF). They also facilitate two groups on a monthly basis for five tiers that house the most P-2 detainees. P-2 detainees are currently housed in approximately seven different tiers. Enrichment programs have been implemented for P2 and GP patients (book club, theater group, yoga, legal aid, knitting, painting, literacy, pride group, substance abuse). Superintendent Baker has been instrumental in improving multidisciplinary communications and increasing enrichment programs. There is also a Mental Health Therapeutic Library to allow patients access to books to utilize as a coping skill.

P3 intermediate MH groups – Each mental health worker assigned to a tier (5-B and 5-F) run three groups daily (Rise and Shine and two therapeutic groups) in the mornings (five days weekly) and three groups (five days weekly) in the evening (two therapeutic groups and medication pass observation). Another mental health worker runs groups on 5-C, 5-D, and 5-H on a weekly basis. Additionally, all mental health specialists were rotated on 10/1/17 requiring a transition and training period, which briefly impacts programming on the floor. A CQI study was conducted for the months of July, August, and September 2017, in order to learn how many P3 patients were receiving group attendance certificates in 5-B and 5-F. The data includes:

July 2017 B = 18 (46% of tier census) F = 10 (26% of tier census)

August 2017 B = 17 (44%)

F = 11 (28%)

September B = 14 (36%)

F = 13 (33%)

Comparing the audit conducted in December 2016-January 2017, where approximately 15% of the detainees on average were receiving a letter, there is a marked increase in group participation. The plan to further increase group participation is as follows:

1. Emphasize the importance of group therapy to the mental health staff during individual and group supervision.
2. Mental health staff will emphasize the importance of group therapy in community groups on the tier.
3. Mental health staff will use different materials, topics, and formats to enhance the group experience.
4. Mental health staff will meet with detainees who frequently refuse to attend groups.

Special Management Unit (SMU) and Protective Custody – Mental health rounds are completed once per week on each tier. Patients are assessed by MH within 24 hours of placement in the SMU (5-A). The number of detainees brought for an evaluation before entering SMU housing is as follows:

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July 2017 August 2017 September 2017

88% (37/42) 84% (37/44) 78% (38/49)

SMU and PC (5-E) are assigned a mental health specialist. SMU and PC patients receive approximately ten hours of mental health groups per week. Additionally, long term P3 patients receive individual therapy session and treatment planning.

Treatment Plans – Patients meet with their tier mental health specialist to create a "treatment goal list." Each P3 patient is discussed in MDT staffing on a regular basis. Both the patients and the entire treatment team are involved in the treatment planning process, resulting in individualized treatment plans for each P3 patient. A CQI project was conducted on the roster of patients housed in RTU-5 on October 5, 2017. Nearly all (98%) of P3 treatment plans are initiated within the first thirty days and updated every 90 days thereafter (96%) on time. The quality of treatment plans has remained consistent. There are challenges when patients move to another tier on the floor because it is unclear who will complete the treatment plan. Outpatient (P2) treatment plans are created by the treating psychiatrist during clinic appointments.

Outpatient mental health (P2) Treatment Groups/ Community Groups- P-2 detainees in RTU-5 receive groups approximately four times per month (C-House, D-House, and H-House). Health Service Requests - Completed according to policy with most patients receiving a face to face assessment generally within 48 hours of receipt of the HSR by a MHS III. Patients sometimes abuse the HSR process by submitting multiple requests within a short period of time. Many of these requests relate to psychotropic medications and sleep disturbance. These issues are addressed at community groups and individual HSRF/IAHI evaluations in order to educate the patients about the process and to increase coping skill behavioral repertoire.

Mental Health and Psychology Clinic – Many patients receive individual therapy services in RTU and in Div. 4 during mental health and psychology clinics for more personalized treatment.

Mental Health Evaluations – The RTU provides 24 hour on-site mental health evaluations (IAHI) and consultation. We are trying to improve consultation with CCDOC to refer appropriate mental health evaluations according to policy (emergent issues, use of force, placement in special management unit, and suspected or confirmed physical or sexual abuse). The unit director brings up any salient issues with CCDOC command staff at the weekly divisional meetings.

Individual Contacts – Each P3 patient is assigned to meet with her tier mental health specialist minimally monthly for an individual mental health contact. One challenge in the consistency of these sessions has been security moving patients to different tiers.

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Linkage and Expressive Arts - We continue to focus expressive arts on P-3 detainees. There is a full-time expressive therapist assigned to RTU-5. Linkage services and discharge medications are provided for P-2 and P-3 patients by two medical social workers. Hygiene – Hygiene is an ongoing concern with P-3 patients. Rise and shine program occurs five days per week on 5-B and 5-F. Patients displaying ongoing, serious hygiene concerns (generally psychotic) are discussed in MDT clinical staffing and if necessary, are admitted to the psychiatric special care unit (PSCU) for increased support and/or a humanitarian shower.
Self-Harm – Women’s Services continues to have a very low self-harm rate. Self-injuries that do occur are often by detainees housed in segregation. Some of these injuries occur in order to get transferred to another tier.
Challenges:
Groups in RTU--Mental health has expressed concerns to CCDOC administration about the availability of officers to monitor group, creating safety concerns that pose potential barriers to providing mental health treatment.
Mental Health Evaluations Prior to Entering SMU Housing-- Command staff in RTU and Division Four will continue to be reminded about the policy related to mental health evaluation for patients entering SMU housing.
Housing in Division Four--Housing all of the P-2 detainees together with increase the efficiency or mental health treatment provision. When the patients are housed among approximately seven tiers, facilitating community meetings for the population is more challenging.
Abusing/Refusing Medications -–In this population, there is always a concern about patients hoarding and abusing the medications. Nursing staff, mental health staff, and correctional staff work together to try to prevent this. Also, patients refusing medications are an ongoing concern as well. The psychiatrist is informed whenever a problem occurs.
Periodically, there is an issue with space availability during the morning shift (on Tuesdays, Wednesdays, and Thursdays), when all staff are present. Also, employees are occasionally reassigned to other clinical areas when operationally necessary, which impacts programming.
RTU Male Services Updates
Patients receiving Intermediate Level of Care (P3) are housed on the second, third and fourth floor

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of the Residential Treatment Unit (RTU) building. Both psychiatric and mental health services in Male RTU have either maintained or slightly increased productivity over the last six months. Dr. Waxler became the Unit Director of RTU male services in June 2017 and coordinates mental health services for males housed in the RTU.RTU Male Services continues to focus on maintaining programming hours offered for P3 detainees, expanding services to the protective custody and SMU tiers, maintaining compliance with treatment plan timelines for intermediate care, addressing P3 overflow, and coordinating with CCDOC to minimize group cancellations. The following overview provides a summary of these efforts.
RTU male services currently has eleven MHS III staff and one MHS II staff. Based on current staffing and required programming for the ten aforementioned tiers, RTU detainees are offered at least 10 hours of group therapy sessions per patient per week.
Detainees attend the following core groups by bed number: Emotional Management, Interpersonal Skills, and Problem Solving. These sessions review relevant skills for all detainees in intermediate care. Voluntary groups are also offered to address the individual needs of patients. MH staff meet individually with detainees for orientation upon their admission to RTU to discuss the treatment program, review behavioral expectations, and identify treatment goals. At that time, detainees rank order their preferences for voluntary groups and are included in those sessions. The orientation document is used to generate each patient’s individualized treatment plan.
Mental health staff absences as well as safety-related concerns remain the predominant reasons for group cancellations. Scheduled programming hours will continue to increase for intermediate care with the addition of mental health specialists. CCDOC and mental health teams continue to collaborate closely to address the most significant obstacles to group programming. The joint schedule that was developed prior to the last DOJ visit to account for group programming as well as recreation continues to be followed and group programming is rarely cancelled due to scheduling conflicts such as barber shop or recreation.
The two most common reasons for a cancelled groups continue to be: 1) MHS staff duty conflict, and 2) availability of supervision. MHS staff duty conflicts occur for a range of reasons. RTU is a dynamic treatment environment, and staff often have to prioritize competing clinical responsibilities, such as providing a mental health assessment to a patient in crisis instead of conducting a group session. Availability of supervision by two officers to conduct on-tier services has also been a challenge. Further, in order to conduct an off-tier group, there needs to be an officer present to monitor the group outside the group room. There are not always enough officers present on the floor to provide this monitoring. Nevertheless, group hours offered continue to be above the necessary 10 hours per patient per week despite these challenges (see attached MH CQI for detailed data on group cancellations).

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Programming on the Protective Custody tier (4E) continues to be well received by detainees. MH staff generally provide on tier sessions, but have conducted off tier groups when space is available and CCDOC approves movement. Initially, medium and maximum detainees were being seen more frequently due to the timing of the groups and “hours out” for those classifications. After realizing this disparity, MH staff have put forth increased effort to coordinate with tier officers and provide equal opportunity for minimum status detainees. Apart from staff absences, the most frequent barrier to programming on this tier has been staff attention to other clinical duties including mental health clinic, interagency evaluations, crisis intervention, and health service request forms. Programming on 4E will increase as mental health staff are added to the team.
There continues to be more P3 patients than available bed space on the Fourth Floor of RTU. P3 patients who are not on the Fourth Floor are considered “P3 overflow.” Generally, these are new patients who are waiting for bed space to open on the main treatment tiers. Assigned MH staff conduct weekly rounds as well as community meetings for P3 patients on the second and third floor. Patients are consistently reminded in these meetings to utilize Health Service Request Forms (HSRF’s) in order to access mental health services while on the second or third floor. A standing item on the weekly MDT agenda is to discuss P3 overflow patients. This discussion is geared to assessing whether there are patients that would benefit from the additional monitoring and access to mental health staff on the fourth floor. The team works to ensure that the length of time a patient spends in “P3 overflow” overflow status is minimal. The number of overflow patients has remained relatively low since the last site visit.
The Special Management Unit (SMU) has posed the greatest challenge for group programming. Whereas Division 8 previously allotted two tiers (3A and 4A) for disciplinary housing, all males in RTU currently serve disciplinary time on 4A. Consequently, detainees who are general population and/or P2 level of care complete disciplinary time on the same unit with detainees in intermediate care. Groups have been repeatedly cancelled as a result of unsafe detainee behaviors, as tier officers needed to respond to the situations or lock down the unit. Other institutional factors contributing to group cancellations on this tier have included a lack of handcuffs, conflicts with “hours out,” and medication pass. These issues continue to be discussed in interagency meetings, where potential solutions are considered. CCDOC recommended the installation of rings to the bullpen in order for the space to become a viable option for group sessions. MH staff continue to collaborate with nursing and tier officers to avoid scheduling conflicts. Treatment verification letters continue to serve as an incentive for participants. The criteria for earning a treatment verification letter was modified in August 2017 from requiring patients to attend at least 75% of their available groups to requiring patients to participate in the recommended clinical services outlined in their individual treatment plan. For P3 patients, this equates to 10 hours of clinical programming per week. The percentage of patients earning treatment verification letters

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has increased for between 17-30% (during last DOJ reporting period) to consistently above 30% over the past three months (see the attached CQI for Treatment Verification Letters).
In terms of treatment plans, each dorm has an assigned MHS III who conducts a core group for the tier and develops a 30-day treatment plan based upon the detainees’ mental health diagnosis and self-report during the initial orientation session. The mental health team then aims to review the treatment plan within 90 days to discuss patient progress, clinical concerns, and recommendations for level of care. Weekly multidisciplinary (MDT) meetings are held on both day and evening shifts to facilitate team collaboration on treatment plans. The clinical team on the evening shift has also added group supervision sessions to meet with patients, discuss clinical goals, and offer feedback to increase the opportunity for the patients to interface directly with the full treatment team. According to MH staff, this time has been especially useful to reinforce concepts discussed in groups and to address clinical issues with detainees as a team. Each tier has an assigned MHS III that has time built into their weekly schedule to monitor, review, and update individual treatment plans on their assigned tier. Compliance with both 30-day and 90day P3 treatment plans has been maintained since the last DOJ reporting period (see attached CQI for Treatment Plan Compliance). The MH team will continue to monitor and complete treatment plans within specified periods.
Treatment plan review during weekly MDT meetings serves as the primary method by which the team monitors the P3 population in attempt to reduce overflow on other floors. Each week, MH staff place names on the MDT list for review due to an upcoming treatment plan revision or due to the patient’s clinical presentation during treatment sessions. All detainees in SMU, PC, and overflow units are reviewed briefly to alert the team of clinical concerns. In addition, the team typically identifies an average of 9 to 10 individuals who are stable for outpatient care each week. MH staff observe many detainees to be highly motivated to remain in the dorm setting. Currently, CCDOC does not have dorm housing for P2/Maximum detainees. As a result, a portion of detainees often attempt to obtain preferential housing in RTU by exaggerating symptoms, requesting mental health treatment, and /or engaging in problematic behaviors.
In January 2017, Cermak administration proposed a therapeutic tier in Division 10 to provide additional support and monitoring for P2/Maximum and Medium detainees. The tier was approved to be started in mid-March. The addition of this tier has increased mental health services for higher functioning detainees while decreasing the number of patients who intentionally return to intermediate care. In September of 2017 a similar programming tier was opened in Division 6 for P2/Minimum detainees. Patients identified as stable for P2 level of care, but appropriate for continued access to programming services are referred to either program depending on security classification.

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Goals for the next six months in RTU Male include: 1) maintaining more than 10 hours of offered programming services per patient per week, 2) continuing to increase percentage of treatment plan compliance from 84% to above 90%, 3) continue to monitor and increase percentage of patients earning treatment verification letters, and 4) maintaining compliance with HSRF response.
Intensive Management Unit Updates
The Intensive Management Unit (IMU) remains on the second floor of RTU (tier 2A). This specialized program was initially designed at the recommendation of DOJ to provide increased structure and support for seriously mentally ill detainees who have demonstrated significant problems in their functioning. The IMU tier houses a maximum of 10 detainees, each of whom reside in a single cell and are encouraged to progress through three successive phases (Assessment and Admission Phase-minimum 2 weeks; Stage 1- minimum 4 weeks; and Stage 2-minimum 4 weeks). Following team discussion, a 4th Phase (Residential) was introduced to accommodate program graduates who would likely deteriorate in a less structured setting. All of the detainees selected for the program have had significant difficulty maintaining safe behavior in other mental health housing locations. Behavioral problems prompting admission to IMU include aggression against self or others, property damage, sexual misconduct, threats of harm, noncompliance, coprophagia, insertion of foreign objects, and ingestion of foreign objects. In the past, the Unit Director and at least one member from CCDOC leadership interviewed prospective detainees prior to admission. Coordinating schedules for the interviews and discussing patients’ subsequent team meetings occasionally caused delay. The team therefore decided to admit detainees immediately after initial discussion, with close monitoring during the two week Assessment and Admission Stage.
At the time of their intake to the IMU program, detainees are presented with initial behavioral plans. Treatment and behavioral expectations of the program are reviewed as well as projected dates of potential advancement through stages. Participants are informed that completion of the program could result in absolution of earned time for previous disciplinary tickets. Additionally, they earn a Letter of Completion, which is addressed to the Court Judge and is signed by the Superintendent as well as the Unit Director of the program. To date, 10 of 26 participants have graduated. Of those graduates, 8 detainees had no further incidents of significant aggression or behavioral problems while housed in CCDOC. Two of the graduates did exhibit problematic behaviors (self-injury and/or aggression towards others). Of the total participants admitted to the program since November of 2015: 11 were discharged to the community or to IDOC prior to completion of the program; 4 were transferred to Cermak due to medication noncompliance or deterioration; and 1 was transferred to a maximum security mental health division due to poor progress.

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Currently, 9 detainees are participating on the IMU program, which is the largest number of members thus far. Three of the detainees are in the Residential Stage, 1 detainee is in Stage 2, 1 detainee is in Stage 1, and four detainees are being monitored in the Assessment and Admission Stage. The program continues to provide more than 10 weekly hours of structured out of cell therapeutic programming. In addition to the groups held in previous years (positive psychology, anger management, substance abuse, communication skills, and coping skills), IMU detainees now have the opportunity to participate in on tier art therapy several times per week. Detainees often continue to work on the drawings, letters, and projects they started in art therapy during unstructured time out of their cell. Officers provide participants with materials located on the unit (markers, colored pencils, etc.) and monitor as they complete tasks.
Feedback regarding the structure and programming of the tier was solicited via “Satisfaction Surveys” administered in September of 2017. The four detainees on the tier at the time identified the following strengths of the program: the small size of the unit, having “undivided” attention of officers and MH staff, snack incentives, and group sessions. They recommended more “activities” and creative methods for reviewing material in sessions. During on tier meetings with the team, participants also requested access to commissary, as several of the detainees were either in or nearing the residential stage. Based upon the feedback of IMU participants, mental health staff have attempted to continue and/or incorporate various activities during group sessions including games and book discussions of reading material patients choose. Commissary has also been added to the specific stages of the program. Detainees in the Assessment Stage and Stage 1 are not permitted to obtain food commissary; however, participants can purchase a total of twenty dollars of food and hygiene products in Stage 2 and can earn full commissary in the Residential Stage.
The treatment team continues to meet weekly in a multidisciplinary team (MDT) staffing to review patient progress and to discuss relevant tier issues. Over the past six months, the team has addressed questions related to commissary, use of the treatment binder on the tier, consistency across shifts, and logistical issues (hours out, mail distribution, incentive schedule, etc.). Individual treatment plans are developed and revised each week based upon staff observations as well as patient self-report. In terms of strengths, the team has put forth concerted effort to individualize treatment plans whenever possible. To illustrate, the members of the team identify patient interests and incorporate those interests into the weekly treatment plan to incentivize progress. Examples of incentives have included: juice from nursing staff with medication compliance, information about sports teams for every day of group attendance, as well as copies of poems or activities with safe behavior. Treatment plans and expectations are reviewed with detainees during weekly MDT meetings held on the tier. At those sessions, detainees meet individually with available team members and are encouraged to express questions or concerns. Team members utilize the on tier MDT to provide feedback to detainees and to review individual treatment goals.

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In the past, consistency of tier officers and implementation of program tenets was a challenge. To address these issues, specific officers were solicited by the team and placed on the tier if they agreed to join. These officers are typically scheduled for the IMU program on predictable days and times, which has been beneficial for detainees as well as mental health staff. On occasion, the officers assigned to this tier are placed on other units and switched with officers who are not normally assigned the tier. Several incentives were posed for the IMU tier officers, but have not been consistently implemented to date. The Superintendent has distributed special certificates to officers at an awards ceremony to recognize their ongoing support of the tier and the IMU patients.
The placement of overflow detainees on the tier has remained problematic. Detainees cited this issue on their satisfaction surveys, noting that groups feel less confidential when overflow patients are present on the unit. Moreover, tier officers have repeatedly cited difficulties managing "hours out" with overflow detainees. The clinical team therefore actively recruited referrals from P2, P3, and P4 placements. In October of 2017, four detainees were admitted to the program and one residential detainee was returned to IMU due to concerns about his potential behavior on a dorm setting. The admission of these detainees will minimize disruption of overflow detainees, but will require careful treatment planning due to challenges posed by the increased census. In particular, seating limitations in the day room will not allow for all detainees to participate in a single group session. Currently, the tier has six tables, with only one detainee cuffed to the table for group sessions. This design was implemented to avoid unsafe behaviors between group participants (e.g spitting, kicking, etc.). The team has discussed the possibility of adding a table as well as a bench with additional seating. Further, the team is in the process of examining the program schedule to separate sessions for Residential Stage participants and to potentially divide groups into multiple sections based on stage in the program and/or treatment need. The most common interruptions to group programming on IMU include, but are not limited to: absences amongst mental health staff (both planned and unplanned), overflow detainees, shortage of handcuffs, and environmental issues (flooding, plumbing, etc.). The IMU program continues to utilize mental health staff from RTU 4th floor. Covering missed groups and adding treatment services may therefore become more feasible as IMU gains a dedicated staff. Toward this end, two mental health specialist positions were added to the 3 to 11 shift within the past month.
Division 2 Dorm 2/minimum and medium Treatment Team Updates
Division Two – Dorm Two houses P2 and M2 (outpatient level of care) patients within a dorm setting. There are ten dorms over three floors, with a census of approximately 44-48 detainees in each tier. Per DOJ recommendations for outpatient care, each dorm is scheduled for at least one on tier group per week. Mental health specialists in the division have assigned tiers and lead groups on varied topics (coping skills, relaxation techniques, communication, psychoeducation, grief and loss, etc.). Staff enter the tier, announce group topics, and facilitate sessions in the day room with willing participants. Group size ranges from two participants to almost twenty,

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depending largely on the dorm as well as the time of group. Several dorms house detainees in the MHTC program, which reduces the number of participants available for some group sessions on the 7 to 3 shift.
Detainees in Division Two, Dorm 2 are additionally offered weekly on tier art therapy sessions. The newly hired staff conducts small groups in the day room of each dorm. These sessions have been well received by participants, who express appreciation for the music and art activities offered. The number of detainees allowed to participate must be limited in order to safely monitor the art supplies. At times, conducting on tier group sessions has been challenging. Detainees and tier officers occasionally resist turning the television off and clearing the day room for sessions. MH staff have requested use of the recreation room on the first floor to conduct off tier groups, however custody has indicated this is not a possibility. Currently, there are no other available spaces for off tier programming in the division. MH staff therefore continue to focus upon providing on tier group sessions.
The medical social worker assigned to the division co-facilitates on tier group sessions for each dorm approximately once per month. In these sessions, the MH staff and MSW collaborate to provide an overview of linkage services and address frequently asked questions. Additionally, the MSW meets individually with detainees to obtain releases of information, plan for discharge medications, and facilitate placements in the community for identified patients who are not participants in CCSO programming (those patient receive discharge planning services from the CCSO discharge planners).
Apart from on tier group sessions, MH staff meet with detainees individually during MH clinics, to address HSRF’s, and for crisis intervention. The clinical team agreed to identify and closely monitor patients with increased clinical need. Those detainees are referred for weekly or biweekly individual sessions with MH staff for additional support.
The MH team in Division Two, Dorm Two has been able to consistently provide on tier group sessions over the past few months. Currently, one staff is assigned to each shift, which is challenging when MH staff are absent or must attend to multiple crises, walk-ins, and HSRF’s. Due to present staffing allocations, services have to be referred to the Urgent Care when MH staff are not assigned to this division. When available, overtime staff has been helpful, but does not provide regular coverage. Another challenge has been times during which MH staff on the second floor conduct individual sessions, MH clinic, and telepsychiatry clinics with supervision being provided by tier officers located near the MH offices while they are also supervising their assigned dorms. Officers in the dispensary are assigned to supervise mental health, psychology, and psychiatry clinics, which has been helpful. Issues related to officer supervision and needed

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assistance with on tier programming during the 3 to 11 shift have been discussed in weekly interagency meetings.
Division 6/Minimum and Medium Treatment Team Updates
Division Six houses P2 patients, along with GP (General Population) detainees, and transgender detainees. In the past, three tiers were dedicated for Protective Custody (PC) housing while one tier was designated for a Special Management Unit (SMU). Within the last three months, the SMU tier was removed from the building and the PC tiers were consolidated to a single tier (1L). Other tiers in the building are designated for the Westcare substance abuse program, the school PACE program, and the VRIG boot camp program.
In June of 2017, approximately 230 P2 detainees were housed over twenty different dorms throughout the building. All tiers were primarily populated with general population detainees, with less than twenty P2 detainees on each tier. Two MH staff were assigned to the building on the 3 to 11 shift, with one staff scheduled to conduct approximately six community meetings for P2 detainees each week. At that time, MH staff were not conducting any off tier groups. Consequently, the MH staff would count the number of P2 detainees on each dorm and select the six tiers with the highest population of P2 detainees. During the on tier community meetings, the P2 detainees were called to the front table of the day room area, where MH staff would conduct a community meeting on various topics. Officers muted the television, which caused significant resistance amongst general population detainees who were also present in the day room. Their use of the microwave and telephones continued throughout the meeting. MH staff expressed safety concerns with this persistent movement in the day room area. In addition, the community meetings were difficult to conduct due to the loud noise of the general population detainees talking and socializing in the shared space. These meetings were discontinued in July of 2017 following consultation with Cermak MH leadership due to the environment not being conducive to effective service delivery and safety concerns.
In effort to provide more effective mental health support in Division Six, the mental health team requested development of outpatient dorms to house all P2 detainees together. CCDOC leadership expressed concerns regarding safety and logistical issues that could arise with the immediate creation of six P2 tiers. However, initial movements were made to create a P2 tier with randomly selected P2 detainees. The detainees placed on the unit were upset about the transfer, expressing concerns they were “singled out” due to their mental health issues. Following further collaboration, Cermak and CCDOC teams agreed to develop one pilot therapeutic tier in Division Six. The tier proposed was modeled after the therapeutic tier in Division Ten and is intended to provide increased support for selected P2 detainees on the mental health caseload. With support of CCDOC, the Therapeutic Tier in Division Six was opened on unit 1K in September of 2017.

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Most of the detainees currently housed on the tier were identified and interviewed by MH staff. However, the tier is also populated with new P2 detainees who have no knowledge of the program and did not necessarily express interest in group treatment. MH staff review the tier list and attempt to meet with these detainees shortly after their placement on 1K to assess their appropriateness for the unit. Occasionally, general population detainees are also placed on the unit when other participants are discharged. Maintaining the therapeutic tier with willing and compliant detainees is a primary concern to preserve the integrity of the program. A weekly list is sent to CCDOC leadership in classification to identify selected program participants as well as those awaiting transfer to and from 1K. MH staff and CCDOC continue to collaborate on the most effective methods to communicate regarding detainee movements on and off the tier. Two mental health specialists are currently assigned to Division Six on the 3 to 11 shift. Recently, two new staff members were hired on the 3 to 11 shift, which will help to provide increased coverage in the building. The therapeutic tier is offered approximately eight hours of on tier and off tier group programming based upon current staffing with mental health specialists, an art therapist, and the assistance of two Unit Directors and a Cermak volunteer who facilitates chair yoga. MH staff have additionally collaborated with the Supervisor of Enrichment Services for CCDOC to increase opportunities for volunteer programming. Specifically, volunteers from the community have agreed to lead the following groups for the therapeutic tier: AA/NA, parenting, and story-telling.
The MH team is currently working on improving the consistency of programming for the therapeutic tier as well as for the community meetings for P2 detainees in the division. MH staff have inquired about use of classrooms during the evening shift, however these rooms could not be secured for off tier P2 groups. The multipurpose room is the only space available for P2 community meetings/group sessions given the elimination of community meetings on predominantly GP tiers. This room is frequently used by volunteer groups and therefore has limited accessibility. CCDOC thus agreed to create a second P2 tier (1J) in October of 2017, which will facilitate the provision of on tier community meetings. The MH team will collaborate with CCDOC to either create additional P2 tiers or to secure at least six time slots in the multipurpose room for weekly group sessions with the remaining detainees on the mental health caseload (over 100).
In addition to the development of the therapeutic tier and the P2 tier in Division Six, MH staff have been increasing support for the Protective Custody tier (1L). At least one MH specialist is assigned to conduct rounds and one on tier group session weekly. The art therapist has also been working on providing at least one off tier group session for these P2 detainees.
Apart from group sessions, MH staff meet with detainees individually to address HSRF’s, during scheduled clinics (Sunday through Thursday evenings), and for crisis intervention. Movement in

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the dispensary area can be challenging at times due to CCDOC staffing, unplanned behavioral incidents, volume of detainees being seen by multiple disciplines, and delays when both GP and PC detainees need to be seen. Despite these challenges, MH staff report strong support from officers in the dispensary who help to facilitate access to patient care. The MH team recently agreed to add two multidisciplinary meetings per month to facilitate communication regarding patient care, behavioral treatment plans, and potential step downs to general population.
Maximum Security Treatment Team Updates
Divisions 9 and 10 house the maximum security outpatient mental health and medical population, as well as CCDOC Special management Units (Div. 9), and general population detainees. The clinical team consists of 9 Mental Health Specialist, 5 assigned to the day shift and 4 to the evening shift. All patient services needed on the overnight shift are handled by the Urgent Care staff.
Since the last site visit the following services continue to be provided by Mental Health Specialists and psychologist for the outpatient mental health population: evaluations for mental health conditions, psychological evaluations and assessments for suicidal risks and assessments of detainees to determine if there are psychiatric concerns regarding placement in Special Management Units by CCDOC. This clinical team also provides therapeutic services which includes mental health and psychology clinics, group therapy, behavior management treatment plans, community meetings, weekly Special Management Unit rounds, crisis intervention, and service response to submitted Health Service Requests and Inter-Agency Health Inquiry forms.
Groups for SMU detainees on Division 9/1E are conducted weekly by Dr. Briney and Dr. Augustine. Mental Health Specialists in Division 9 now have designated clinical office space which allows the treatment team full autonomy in scheduling clinics. Since the last site visit there has been continued increase in number of groups and number of detainees served in groups in Division 10. Over 200 groups were held from May to September and over 6,000 patients served in groups.
Mental Health leadership and staff submitted a proposal for an enhanced services Therapeutic Tier in Division 10 on January 20th, 2017 and CCDOC approved the Therapeutic Tier during the week of March 13th. One of the day shift Mental Health Specialist on Division 10 has primary responsibility for the Therapeutic Tier, 2B Division. The psychologist coordinates with other providers to schedule, facilitate and enhance services to the Therapeutic Tier and Mental Health Staff began providing services on the Therapeutic Tier on March 19th, 2017. The program schedule can be found in the PDF appendix.
The detainees on the Therapeutic Tier completed a survey in September which marked the six month anniversary of the establishment of the Tier. The results indicate that the majority of

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participants who were on the Tier at the time of the survey are very satisfied with the programs offered 30/35, 86%, 3 were somewhat satisfied 8% and 2 were neutral, 6%. The three detainees who were somewhat satisfied listed the following reasons: one was on the Tier for only a week and did not have the opportunity to participate in all groups, one wants to lock up early-after groups and one gave no reason. Of the two neutral results, one wanted the Tier to be like RTU and one did not like the Art Group schedule. The detainees also provided feedback on Yoga indicated that participating has aided with sleep and bodily aches. These results can be found in the PDF Appendix. Additionally, the statistics show a significant post-6 month decrease in self-injuries and disciplinary incidents for detainees admitted to the Therapeutic Tier when compared to preadmission incidents of self-injury and disciplinary infractions. Please refer to PDF Appendix. The detainees on the Therapeutic Tier also decided to represent their commitment to the goals of the Tier by choosing the symbol of a phoenix rising from the ashes and by adding the following saying to the symbol “We will rise up and make a change”.
The clinical team continues to work to address a number of challenges in order to increase the efficiency and effectiveness of service delivery. The clinical office space available for provision of Mental Health services on Division 10 continues to pose a potential risk due to the room layout that results in physically close proximity between staff and detainee. The goal of achieving 100% compliance in Special Management Units (SMU) pre-placement/within 24 hour evaluations poses some challenges. The following factors continue to impact this compliance: instances of no movement of detainees due to safety concerns, detainees refusing to be seen, MHS staff are not always informed in real time when a detainee is being placed in SMU or when the detainee is removed and returned after 30 days/24 hours out, and detainees are sometimes not referred as being SMU bound when they are returned from outlying counties and hospitals. In Division 9 several detainees present a challenge with their chronic pattern of self-injurious behaviors and suicidal gestures and threats. Assessment of the identified patients indicated that the detainees do not present with serious mental illness but engage in disruptive behaviors due to difficulty controlling impulses and achieving identifiable goals (i.e. movement out of SMU, changes in housing location, visits to offsite hospitals, etc.). Several multidisciplinary meetings were held and Mental Health Leadership and staff in Division 9 submitted a draft proposal for a Behavior Management Unit Pilot Project on February 7th, 2017 for CCDOC’s approval which is still pending. The purpose of the proposed unit would be to provide a structured therapeutic setting for patients with institutionally disruptive behaviors that are unrelated to serious mental illness.
A collaborative project related to clinical scheduling and patient movement was launched div. 9 in April 2017. All Cermak scheduled clinics are automated to produce an electronic movement list for custody. The project was recently expanded to Division 10. This has had a positive impact on access to care challenges, as it has enabled both agencies to identify and correct barriers in real time.

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Compound Special Management Units:

Compound SMU housing was assessed on 10/18/2017 with the following data captured:

 Compound Census as of 10/18/2017: 6,939

 RTU SMU and PC Census 10/18/2017: 62 (23 in disciplinary SMU, 39 of them are in

Protective Custody )

 Out of 23 Disciplinary SMU RTU detainees- 14 are P3’s (0.2% of total jail population)

and are 9 P2’s.

 Division IX Non PC SMU Census ( all P2’s)- 77

 Total SMU P2 and P3 population on the compound – 100 (excluding Protective Custody

Population) ( 1.4% of the detainee population and 4.79% of the Mental Health caseload

population)

 Average Non PC SMU population on Mental Health caseload (P2 and P3) from June

2017 until October 2017 - 81.

 Average Non PC SMU population percentage of Mental Health caseload (P2 and P3)

from June 2017 until October 2017- 3.82%.

 The number of P2 and P3 patients in SMU housing as a percentage of the total mental

health caseload has declined from about 5% to about 3% from September 2016 until

October 2017.

P2 & P3 PTS IN SMU BY MONTH [SEP 2016-OCT 2017]

OC NO DE

MA

MA

AU

OC AV

TIER

SEP T

V

C JAN FEB R APR Y JUN JUL G SEP T

E

RTU 4A

13

9 11

6

6

9

9

9 11

6

8

8

5

7 8.4

RTU 5A

10 12

9 12 11 12

8

6 13 11

8 12 10 10 10.3

9 1E

10

7

8 10

8

9

8

6

4

6

1

5

4

4 6.4

9 1F

11 12 13 10

8 10

9 12 11

9

9

9

8

9 10.0

9 1G

39 34 39 37 32 27 29 27 32 34 32 29 30 27 32.0

9 1H

17 20 18 13 16 18 15 16 11 13 15 11 10 12 14.6

TOTAL MH
CASELOAD
AVE %

100 94 98 88 81 85 78 76 82 79 73 74 67 69 81.7

208 209

215 215 213

210

209 210

212 215 212

7

1 2137

9

5

8 2135

3 2093

5

6 2124

9

3

1

4.8 4.5 4.6 4.1 3.7 3.9

3.6

3.7 3.4 3.4 3.1 3.2 3.8

% % % % % % 3.6% % 3.9% % % % % % %

SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT

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P2/P3 PTS IN SMU HOUSING
AS % OF MH CASELOAD, BY MONTH SEP 2016-OCT 2017
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
 SMU settings: DOC and Cermak staff work together on overcoming inherently lower accessibility of patients to care; the overriding principle remains being able to provide essential psychiatric and mental health services regardless of housing. Very helpful was the establishment of the Compound wide Access to Care Workgroup with the participation of the Cermak operational leadership and most senior CCDOC executive leadership with the focus ( as the first priority on further improving access to care in Division IX which houses significant behaviorally problematic/institutionally disruptive P2 detainees in various SMU units). CCDOC concentrated most of the P2’s in SMU in Division IX on the same tier – 1G –with the goal of improving security and supervision as well as access to essential mental health services. CCDOC moved all SMU (Non Protective custody) to Division IX and presently there are no Non PC SMU tiers remaining in Division VI. The same movement took place in Division IV and all SMU detainees are housed on the fifth floor of RTU.
 SMU for P3’s Programming statistics can be found in elsewhere in this report.  Cermak staff continues to work on modifying conditions of confinement for SMI
populations housed in SMU setting in RTU 5A (Female Special Management Unit). GP and P2 classified female detainees both averaged 10.4 days in SMU. Female P3 patients averaged 3.6 days in SMU across review dates. There was only a single outlier among the women; she was a P2 classified detainee who had been housed in SMU for 63 days on October 19th, and had been released from SMU by October 24th. Aside from this individual, no other outliers were identified. RTU 5A CQI SMU Length of Stay Study can be found in the PDF Appendix.  Cermak continues to strive to modify conditions of confinement for those who are housed on 4A (SMU male tier). According to the results of a randomized sampling, overall, P2 patients had an average LOS in SMU of 17.6 days, and P3 patients had a LOS of 6.1 days. The average LOS for both groups falls well within federal guidelines. There were no male RTU SMU outliers identified for those dates. RTU 4A CQI SMU Length of Stay Study can be found in the PDF Appendix.  Modification of conditions of confinement for those individuals with Serious Mental Illness whose time in SMU exceeds 14 days (provided that they serve consecutive, and not concurrent, disciplinary tickets) would consist of providing more out of cell time and additional therapeutic programming to them. DOC Disciplinary Unit continues to issue

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tickets for P3’s that do not exceed 14 days. Tickets do not always run concurrently. Cermak continues to provide structured therapeutic programming for SMI detainees in SMU 4A, described elsewhere in the Cermak October 2017 updates. Detainees remain tethered to stationary furniture during out of cell group structured therapy/activities. Cermak will continue to target 10 hours of structured activities weekly/10 hours unstructured activities weekly provided to these detainees. Programming activities on the male tier have been at times affected by institutionally disruptive detainees. RTU SMU houses detainees with M3 and P2/No P alerts and many of these detainees are high functioning and do not have Diagnosis of SMI. Detainees with higher level of functioning, when introduced into the milieu with more regressed poorly functioning patients, have a tendency to adversely influence more regressed individuals. The importance of not introducing potentially predatory detainees into the RTU SMU environment is recognized.  Cermak MH Department furnishes SMU detainees with the following services:
o SMU rounds weekly ( in addition to weekly PCS rounds) o Psychiatry appointments ( regularly scheduled and walk ins) o Individual Behavioral Management Treatment Plans o Other essential services –individual supportive counseling , access to emergency
and routine care as per DHSR process, crisis intervention, etc. (commensurate with their level of care)
In Division IX new clinical space was dedicated on 1S. A storage room was repurposed to allow seeing detainees for MH and Psychiatry appointments. A desk with EMR computer, patient chair, a wall ring (to tether detainees to) were all installed to enhance security during sessions. Significant effort is made to reduce SMU patients’ movement within the building and, even more importantly, outside the building. What causes self-injury and acting out is multifactorial and, yet, it is believed that many detainees engage in acts of self-harm and other acting out in order to secure movement and break the monotony of SMU confinement. Telehealth services continue to be utilized in order to minimize the incentive that movement to appointments represents to many
detainees in SMU. Additionally, reducing the frequency and length of movement reduces the number of incidents of the use of force which happens to increase during transit.
November 2017 Metzner assessment: It is also encouraging that another “therapeutic” housing unit has been opened in Division 6 to serve as a transition for inmates being discharged from the RTU. This housing unit was opened during September 2017. During the morning of November 14, 2017 I interviewed inmates in a community meeting like-setting within this housing unit. Inmates reported receiving at least 2 to 3 group treatments per week, which they described as being very useful. There clearly was a therapeutic milieu established within this housing unit. I also observed parts of an art therapy group. All the inmates on the unit actively participated in this group, which was performed in a very competent fashion by the art therapist.

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The RTU patio has significantly been improved from the perspective of equipment being located within the patio such as basketball hoops and a ping-pong table for both male and female inmates. The winterization of several of these patios has not yet occurred. An outside exercise yard is in its early phases of construction.
During the afternoon of November 13, 2017, I interviewed inmates in a community meeting-like setting in RTU units 5F (a medium-maximum security female dormitory), 5B (a minimummedium security female dormitory) 4D (a minimum-medium security male dorm), 4F (a mediummaximum security male dormitory) and 4B (a minimum-medium security male dormitory). Inmates were generally in agreement that the offered mental health groups were very beneficial to them with many of these groups being offered in a group room off the unit. Access to groups in Unit D was problematic related to cancellations, which was in the process of being remedied. With few exceptions, RTU inmates were being offered at least 10 hours per week of out of cell structured therapeutic activities.
Access to outdoor patios was problematic in the male dormitory units, which was also going to be remedied in a timely manner. Medication continuity issues were not present.
The male inmates described issues related to lice and reportedly bedbugs. This issue was discussed with both correctional and medical staff, with appropriate interventions taking place. Other issues voiced by inmates again related to conditions of confinement, such as access to cleaning supplies and the quality of the food. However, these issues did not appear to be much different from previous site visits. Specifically, complaints about access to reasonable cleaning supplies in the past were not substantiated when consultation was obtained with the monitor for sanitation.
Some RTU inmates complained about lack of access to a toothbrush, which appeared to be confirmed related to inventory issues.
During the morning of November 15, 2017, I attended parts of 2 group therapies being offered to male RTU inmates and 2 group therapies being offered to female RTU inmates. The inmates were actively engaged in these sessions, which were competently directed by the mental health therapists.
The male Intensive Management Unit (IMU) is located on the second floor of the RTU. This specialized 10 bed capacity program, designed to provide increased structure and support for mentally ill detainees who have demonstrated significant problems in their functioning, continues to evolve in a very positive manner. I interviewed four of the eight inmates in this unit, who all

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described the programming and out of cell time (3-6 hours per day) to be very beneficial to them. The correctional officers and mental health staff clearly had good working relationships with each other as well as with the IMU inmates.
My previous concerns relevant to psychiatric staffing in the RTU have been adequately addressed.
P2 level of care inmates in Division II, Housing Unit S, verbalized many complaints regarding access to mental health services on this unit, which were similar to complaints reported during prior site visits. They included reported poor access to the psychiatrist and medication continuity issues. However, these complaints in the past were not substantiated by reviewing healthcare records and/or talking healthcare staff.
During the morning of November 14, 2017 I observed the mental health rounding process within the SMU located within Division 9, which was done in a competent manner by the mental health specialist.
I also observed inmates in a community meeting-like setting within Division 10 in Unit 2B, which is the “therapeutic” P2 housing unit during a psychoeducational group that reviewed issues relevant to obsessive-compulsive disorder. This unit clearly had a therapeutic milieu established. Inmates were actively participating in the psychoeducational group.
Recommendations: As resources allow, create other therapeutic mental health housing units. The mental health transitions center (MHTC) continues to provide an important re-entry program for mental health caseload inmates.
e. Cermak shall ensure that treatment plans adequately address inmates’ serious mental health needs and that the plans contain interventions specifically tailored to the inmates’ diagnoses.
Compliance Assessment: Substantial compliance (4/17)
Factual Findings:
November 2017 Cermak Status Update Please see Appendix for Treatment Plan QI Audits for each level of care.
Intensive Management Unit (IMU) staff generates Multidisciplinary Treatment Plans called SelfManagement Housing Plans for each individual patient housed in IMU with weekly updates.

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Interagency Behavioral Management Plans continue to be developed as needed by Unit Directors in concert with Chief Psychologist, Chief Psychiatrist, and the full multidisciplinary team for more complex or difficult cases throughout the compound.
 P4 (Psychiatric Special Care Units): Psychiatric Special Care Units patients have completed treatment plans within 72 hours of admission to the Psychiatric Special Care Unit (PSCU) by QMHP and the Treatment Team with a review and update triggered by changes in acuity (such as placement in therapeutic restraints or administration of emergency medications) and failure to achieve goals, but no less frequently than weekly.
 Once patients within PSCU’s are determined to require subacute level of care, with regard to the frequency of Treatment Plan reviews, they will have their Plans reviewed by QMHP and the Treatment Team every 30 days for two months. After that, patients within PSCU’s requiring chronic level of care will have their treatment plans reviewed no less frequently then every 90 days by QMHP and the Treatment Team from that point forward.
 P3(Intermediate Care): Mental Health Intermediate/residential level of care patients have completed treatment plans by a QMHP within 30 days of admission to that Level of Care, with review and update at least every 90 days thereafter.
 P2(Outpatient Care): Mental Health Outpatient level of care patients have completed treatment plans by a QMHP ( Psychiatrists) within 45 days of admission to that Level of Care, with review and update at least annually thereafter. New individualized free standing Master Treatment Plan Templates were introduced in Cerner in January 2017. The new Master Treatment Plans allow to create more individualized and focused plans as they incorporate: reflection of collaboration with the inmate, frequency of follow up for evaluation and adjustment of treatment modalities, referrals for lab work for medication monitoring, instructions about adaptation to the correctional environment, documentation of treatment goals and objectives, notations of clinical progress. It is still allowable to supplement that Template with the Rx plan pertaining entries within the power notes. The ultimate goal remains is to create individualized Master Treatment Plans for every patient in P2 Level of care within the requisite time frame while addressing detainees’ mental health needs and have them updated three times a year/when goals are failed ( current Policy requires annual updates).
 Although the Policy dictates that treatment plan updates/revisions are undertaken annually, Providers are encouraged to do so more frequently, as clinical needs dictate, or when goals fail. The aggregate data demonstrates that Providers generate (new Treatment Plans) and revise (existing Treatment Plans) 390 times a month on average with P2 monthly population averaging 1661 across the compound since February 2017. The data also reflects that a significant number of treatment plans is being generated in Division 2 Dorm 2 (less acute area of the jail where many low security misdemeanants with high turnover rates are housed) and Division X (high security detainees with P2 level of care). Raw data collected suggests that Providers and PA’s have been creating and revisiting template Treatment Plans with increasing frequency since the template was introduced in

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January 2017. The fact that numbers are decreasing in most of the areas, but Division II, is a reflection that most of the pt already have had initial treatment plans generated ( the burst following the start of the template in February 2017 ) and now most of the activity in that domain is due to updates and revisions.  Care Level specific CQI studies for Treatment Plans can be found in the PDF appendix.  Additionally, Cermak collected data on the number of P2 Level of Care Detainees who receive no medications. It is recognized that the time expenditure and complexity of treatment management is decreased for these detainees. Aggregate data shows that 319 (19%) P2 Level of Care patients receive no psychotropic medication. Total number of P2 patients as of 09/14/2017 is 1,670.

November 2017 Metzner assessment: Treatment plans are being completed within the policy and procedures’ required timeframes as confirmed by QI studies.

Recommendations: Continue to self-monitor.

f. Cermak shall provide 24-hour/7-day psychiatric coverage to meet inmates’ serious mental health needs and ensure that psychiatrists see inmates in a timely manner.

Compliance Assessment: Substantial compliance (11/16)

Factual Findings:

November 2017 Cermak Status Update

Mental Health Department Vacancies. October 2017

Divisional Chief of Psychiatry Associate Director of Correctional Psychiatry FT Psychiatrist PT Psychiatrist PT Consultant Chief Psychologist Psychologist Physician Assistant Social Worker Mental Health Director

ACCOUNT # 110 110
110 133 155 110 110 110 110 110

VACANT
0 0
0 3 2 0 3 0 1 0

FILLED SUM

1

1

1

1

15

15

2

5

1

3

1

1

7

10

2

2

6

7

1

1

% VACANT 0.00% 0%
0.00% 60.00% 66.70% 0.00% 30.00% 0% 15% 0.00%

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Art Therapist MHS Administrative Assistant Medical Assistant

110

0

4

4

0.00%

110

17

67

84

20.20%

110

0

1

1

0.00%

110

0

1

1

0.00%

Total

26

110

136 19.12%

FTE’s Psychiatry October 2017

Chair (1)

1.0 (Kelner)

Associate Chair (1)

1.0 (Thomas)

Attending Psychiatrists

14.8 (Advani, Howard, Marri 0.8, Menezes, Paschos, Ward, Bednarz,

McNeal, Haq, Miller, Kartan, Canelas, Libeu, Garbharran, Mason)

Psychiatric PA (2)

2.0 (Balawender, Greiner)

Psychiatrists (133 acct)

0.8 (Ramic, Friedman)

Consulting Psychiatrist

0.3 (Binius)

______________________________________________________________________________

Total Functional FTE

19.9

FTE’s Psychology October 2017

Chief Psychologist (1)

1.0 (K. Key)

Psychologists (10)

7.0

(Briney, Kaniuk, Waxler, Sillitti, Nunez, Augustine, Butler)

______________________________________________________________________________

Total Functional FTE

8.0

Psychiatric Vacancies for Full Time Psychiatrists October 2017

Psychiatry Full Time

Total 15

Filled Vacancy Rate

15

0%

As of September 2017 Functional Vacancy Rate(FVR): # of fulltime positions/FTE’s – # filled full time positions/FTE’s – hours paid Acct. 133 ( part time) - hours paid Acct. 155( part time) hours paid vendors( Locums) – hours paid overtime/moonlight – supplement by mgmt. =0.0%
Locums Psychiatrists are separated from Cermak in August 2017
Summary for Psychiatry.

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Direct service hours and participation in MDT meetings constitute 100% of FTE’s hours.

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Psychiatry Staffing -October 2017

Oct-17

PSYCHIATRY

Psychiatric Special Care Units

PsychiatryAllocations:

FTE

2 North: 3 Psychiatrist+PA with 7-day Coverage(RFX1.7)

3.3

2 South/Southeast: 2 Psychiatrist with 5-day Coverage

0.9

2 West: 2 Psychiatrists with 7 day coverage(RFX1.7)

1.7

2 E: 1 Psychiatrist Once a month coverage

0.1

Total

5.8

Physician /patient ratio on acute units> 1:15

Physician /patient ratio on subacute units> 1:30

Divisions with P2Housing/OutPatient

PsychiatryAllocations:

797 daily average population in Min /Med Security Divisions ( II,IV,VI)

2.8

670 daily average detainees in Maximum security Divisions X and IX

2.3

175 daily average detainees in SMU, including PC ( Division IV,VI,IX,X)are absorbed into P2 population

Total

5.1

Physician/patient ratio for maximum security P2-1:291

Physician/patient ratio for minimum security P2-1:284

Residential Treatment Unit

Psychiatry Allocations:

Absorbs SMU P3 and P2 Populations( daily average 18)

Absorbes Intensive Management Unit ( average daily census 6 )

Male and Female(average daily population is 400 P3 and 190 P2)

RTU P2 population is concentrated on the 2nd,3rd and 5th floors

1 FTE is assigned to P2, SMU, and IMU combined

1

RTU P3 population is concentrated on the 2nd,3rd,4th and 5th floors

5.2 FTE assigned to P3

5.2

Physician/Patient ratio for P2 -1:214

Physician/Patient ratio for P3 -1:76

Total

6.2

RCDC Monday, Tuesday, Wednesday,Thursday, Friday**

Psychiatry Allocations

1.8

NOTE:* RCDC has shortened shifts- 5hours

NOTE:** 2 Psychiatrists (1 for Male RCDC, 1 for Female RCDC)

Total

1.8

1FTE onsite hours =52 weeks=2080hours per year Chief Psychiatrist does not provide direct service hours Psychiatrists do not perform administartive duties Associate Chief of Psychiatry provides direct patient care

Grand Total

18.9

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o The main accomplishment is the hiring of 4 additional Full time correctional Psychiatrists to fill all the available 15PID’s and elimination of vacancies for this group.
o One Part time Psychiatrist was recruited and hired. He provides weekend coverage in PSCU. One Part time Psychiatrists is being recruited.
o One Part time Psychiatrist resigned and present vacancy rate in that category is 60%. The majority of part-time (Account 133) Psychiatrists are committed to working between 8 and 20 direct service hours. There is one (and one remains vacant) filled position of a Consulting Psychiatrist. The rate of compensation for this position has been made sufficiently attractive.
o Even though Telepsychiatry has undergone contraction on the compound, in addition to flex time arrangements, it continues to be an important recruitment and retention instrument. Telepsychiatry clinics function successfully in RCDC and Division D2D. The rate limiting step in the maintenance of Telepsychiatry on the compound remains the availability of Telepsychiatry Clinic Attendants. One permanent full time Attendant was hired and works on campus. Many Providers request increased Telepsychiatry shifts availability and are interested in providing Telepsychiatry services. Strategic view of Telepsychiatry at Cermak should accommodate such requests and afford expanded Telepsychiatry opportunities to staff, even if previously Telepsychiatry was seen primarily as a temporary solution to attract Locums providers to alleviate staffing shortages.
o With the ultimate goal of creating physician/patient ratios affording detainees adequate and timely evaluations, treatment, and follow up consistent with standards of correctional care.
o Coupled with new staff availability, is the project to open additional Psychiatry assignments in RCDC on the weekends. A proposal was submitted to Labor to vet with SEIU in term of its impact on present staff. Senior Cermak Leadership has been supportive with regard to making Psychiatry available in RCDC on Saturdays and Sundays. These new shifts would enable Psychiatrists to work in Intake via Telepsychiatry links.
o 2 Physician Assistants are employed. Two MH PA’s exceed Departmental expectations in terms of productivity and quality. PA’s deployments have been diverted to less acute area and not PSCU.
o As a future direction, Chief of Psychiatry collaborates with Cermak CCO to augment current staffing with Pharm. D’s and potentially expand the lines of services where PA’s are deployed. Position had been reposted.

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o A position of the Associate Director of Correctional Psychiatry was filled. Dr. Thomas brought with him vast correctional and leadership experience and remains a major asset for the Department.

o Contracts for three locum tenens agencies have been extended into 2017. However, based on recent hiring trends and successful recruitment, Cermak Mental Health Department, in the short run will not need to rely on Locums Providers. Both Locums Providers and two Locums Telepsychiatry Clinic Attendants were separated, while contracts remain active.

o Ongoing current advertisement efforts by CCHHS involved postings in industry publications, including the AAPL quarterly letter, communication with the local feeder schools, and participation in local Psychiatry Job Fairs.

o Additional staff hired in the CCHHS’s Credentialing office provides increased support to engage applicants and expedite processing. Cermak’s Finance Department facilitates monthly conference calls with HR and Credentialing Department to coordinate onboarding and hiring issues.

o “Advanced Clinical Process (ACP)” at Cermak has been in place since November 2015. The Advanced Clinical Process was created to assist Cermak in filling hard to fill credentialed positions. The ACP process has helped enhance the recruitment process by allowing for the participation of departments to solicit candidates to submit resumes / CVOs to a centralized mailbox, which allows for the expedited review and determination of candidates meeting minimum requirements. Due to success of this pilot, the ACP process is now implemented CCHHS wide.

o As an important recruitment tool Cermak Psychiatry continues to support student and Psychiatry residents’ rotations/training on site from nearby medical schools (Rush+ UIC’s). University of Chicago signed a Programmatic agreement (in addition to previously existed Master Education Agreement) and the first 4th year resident in expected to start his rotation in October-November 2017.

o RTU staffing

Psychiatry Psychology/Unit Director Social workers

Mental

Health

Specialists (cover RTU

RTU 5th floor females
6.2 ( 5.2 for P3 and 1 for P2) 1.0
1.2+ 1.0 Expressive therapist 4 MHS III + 2 MHS II in am 3 MHS III in pm

RTU 4th floor(+ 2nd and 3rd floors)
1.0
1.0+ 1.0 Expressive therapist 6 MHS III + 1 MHS II in am 5 MHS III’s in pm

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5th floor and Div. 4 for female services) Population as of 9/22/2017

(1 MHS III on Overnight for RTU) P3 96 P2 66 (162)

P3 231 P2 111 (342)

 A scheduling Pilot started in the spring of 2017 in Division VI. It was designed to ensure that the amount of prescribing clinician time was sufficient and led to thorough clinical encounters. It allots 40 minutes for an Initial Assessment and 20 minutes for follow up sessions. The amount of time allotted to initial psychiatric examinations was sufficient to conduct thorough initial evaluations, conduct medical records review, and enter documentation in EMR. CQI was conducted to assess the results and further expansion of the Scheduling Pilot was recommended for implementation in the rest of Divisional Clinics across the compound. In the meantime, the Access to Care Collaborative DOC/Cermak Pilot had been expanded from Division IX to all divisional clinics in CCDOC. Information about the projects effectiveness is available elsewhere outside of this report. CQI study is available in PDF appendix.

 The Access to Care Collaborative DOC/Cermak Pilot in Division IX was expanded in July 2017 to the whole CCDOC compound. It automated communications related to patient movement and is likely to increase movement to clinic efficiency. Patient movement to clinics is being addressed at the most senior levels of CCDOC and Cermak Leadership. The Access to Care group convenes twice a month to study trends and find solutions to compound wide access to care issues.

 Clinical Performance and Enhancement Peer Review Process was developed by the Chief of Psychiatry and the CQI study in March 2017 allowed to identify some outliers in terms of their adherence to safe practices. The results of the secondary analysis indicated that Providers who did not adhere to the standards of evaluation and documentation in many cases did have sufficient time to meet expectations and further in training and individual supervision will be used as corrective interventions. Additional supervision and explanations/training were provided. A repeat study was conducted in June 2017. CQI study results reflective of the ‘post intervention’ clinical practices is available in the PDF Appendix.

 Frequency of contact with Providers study was undertaken in all the Levels of Care to address concerns that patients are dealing with unreasonably high waiting times. The results of this CQI study are available in the PDF Appendix.

 Issues pertaining to quality of psychiatric practice have been addressed in two CQI studies addressing readmissions to PSCU and polypharmacy with second generation antipsychotics. Both studies reflect statistical trends consistent with best community national practices. Lack of published data did not allow to directly compare rates of

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readmissions and polypharmacy for SGA with best correctional practices. CQI studies are available in PDF appendix.
Summary for Psychology: There is a total of 10.0 FTE psychologist positions (excluding the
Chief Psychologist position) with a current vacancy rate of 30% (3 FTE). Cermak has lost several candidates in later stages of their hiring process due to the fact that their internships were not APA approved. Cermak MH Leadership has worked with the CCHHS Credentialing Committee/Executive Medical Staff, and SEIU to modify previously existing minimum job qualifications from having APA certified predoctoral internship to the APPIC accredited training. The CCHHS Credentialing Committee approved a request to modify the minimum qualifications for this job title and now the minimum job description for Correctional Psychology includes the following language: “Completion of a pre-doctoral internship at a program accredited by the American Psychological Association or listed with the Association of Psychology Post-Doctoral & Internship Centers (APPIC)”.This step is designed to expand the pool of prospective candidates, while deferring to MH Leadership to vet deserving candidates and further strengthening the posthiring Professional Evaluation Process. Two Correctional Psychologists are in credentialing under the set of eligibility criteria. Cermak has submitted a request to fund 2 post-doctoral Psychology Fellows to work under the supervision of the Chief of Psychology, to provide diagnostic assessment, crisis intervention, intake evaluations, group and individual therapy, consultation with multidisciplinary treatment team, projective and objective psychological testing, security and civilian staff training, and supervision of practicum students. Unit Directors/ Psychologists have been rotated in the end of May 2017. Said rotations serve to prevent burn out and fatigue among Psychologists as some areas of CCDOC present heightened acuity of pathology and increased demands in terms of providing coverage and addressing MHS discipline.
Summary for Mental Health Specialists: As of October 27, 2017, there are 62 Masters-degreed mental health specialists, 5 Bachelorsdegreed mental health specialists (all are expected to complete their Master’s degree and obtain licensure on or about December 2017). Beginning in February 2017, the department initiated a mandated overtime process for mental health specialists. The psychologists managing the various teams established minimum staffing levels needed to perform at least 80% of all activities for each shift. When staffing levels fall below this threshold, volunteers are sought to cover the open shifts. However, when there are no volunteers, staff working an existing shift are mandated to work the next shift. To date, the department has spent 237% of the amount budgeted for OT in FY2017. Almost all of the overtime was incurred by mental health specialists. Out of the 14, 269.4 hours of overtime worked between December 1, 2016 and October 14, 2017, mental health specialists worked 13,385.3 hours. This is about 94% of the total overtime hours—or the equivalent of 7.6 full time mental health specialists. It is expected that overtime costs will be drastically cut once the existing 17 vacancies are filled by the end of calendar year 2017.In addition to overtime pay

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for hourly employees, psychiatrists are able to receive additional pay for working hours above their regularly scheduled shift hours.
Summary for Art Therapists and Social Workers: One additional PID was created and filled in the summer of 2017 bringing the number of activity therapists to four (the highest in Cermak history). There is currently one vacant medical social work position that is in the process of being filled.
November 2017 Metzner assessment: A major achievement has been accomplished in the context of hiring psychiatrists (currently no vacancies), beginning to hire additional mental health specialists, and decreasing the psychologist’s vacancies. Decreasing the overall mental health staff vacancies has resulted in improved mental health services at every level of care. This assessment is supported by a comprehensive set of quality improvement studies.
Recommendations: Continue with the aggressive recruitment and retention process.
g. Cermak shall ensure timely provision of therapy, counseling, and other mental health programs for all inmates with serious mental illness. This includes adequate number of Qualified Mental Health Staff to provide treatment, and an adequate array of structured therapeutic programming. Cermak will develop and implement policies and procedures defining the various levels of care and identifying the space, staffing, and programming that are appropriate to each identified level of care.
Compliance Assessment: Substantial compliance (4/17)
Factual Findings:
November 2017 Cermak Status Update
Please see Update in 59f.
h. Inmates shall have access to appropriate infirmary psychiatric care when clinically appropriate.
Compliance Assessment: Substantial compliance (11/16)
Factual Findings:
November 2017 Cermak Status Update

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2N (males) and 2W (females) are the Psychiatric Special Care Units within Cermak Health Services that provide psychiatric/mental health services to a population of acute, sub-acute, and chronic individuals. A psychiatrist meets with each patient within 24-hours of admission and then daily thereafter. Structured group programming is delivered daily to patients, which range from a “Rise and Shine” group focusing on hygiene/ADLs, to “Community Meeting/Unit Orientation,” as well as more clinically focused groups such as “Self-Esteem” and “Symptom Management.” Patients on PSCU have access to a Mental Health Specialist III (licensed clinical staff) 24-hours a day, 7 days a week. Structured programming is delivered 7 days a week on both the 7-3 and 3-11 shifts. Additionally, patients have frequent contact with medical social workers and an expressive therapist.
Programming Clinical groups and expressive therapy take place both in the day room and in the small group room and generally engage patients in discussing topics such as Anger Management, Coping Skills, Symptoms Management, Understanding Mental Illness, etc.
Patients housed on the Special Care Units are seen by a Mental Health Specialist during rounds on each shift, and they have access to a licensed Mental Health Specialist 24 hours a day. Patients are engaged in the milieu or cell front, if necessary for security reasons. Patients typically meet with a psychiatrist or physician’s assistant 5-7 days per week. Patients in need of additional support meet individually with the psychologist, expressive therapist, or mental health specialists.
A QI Project was initiated in May 2016 to ensure the accuracy of the reported dayroom hours. The QI entitled “Cermak Dayroom Hours” provides detailed information comparing the hours recorded by Mental Health staff with video footage of the dayrooms on 2N and 2W. The unit schedules aspire to provide 12 hours of open dayroom time every day where patients have access to care and are provided with 6- 8 hours of structured programming. For this reporting period, 2N patients were in the dayroom an average of 10.3 hours per day.
Group programming hours on 2N and 2W have remained consistent at 6.2 hours every day (2W = 43.1 hours per week/ 6.2 hours per day). The Mental Health department has worked with CCDOC leadership to decrease and/or prevent groups from being cancelled. This has increased access to care in terms of psychiatry, nursing, as well as group programming. Both units have experienced a higher than usually acuity level, high profile patients, and aggressive patients, which limits the patients allowed in the group room.
Several approaches/solutions have been implemented to prevent dayroom closure including: 1) placing a newly admitted patient who requires a single cell in a room while group takes place and

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then after the dayroom hours return the patient to the dayroom, 2) placing the patient in the back hallway in a chair or “boat” bed and provide security supervision, and 3) boarding more stable patients on other second floor units if there is available space. There has also been an effort to increase programming offered in the small group room. This provides increased confidentiality and a more intimate setting for patients to engage in group therapy.
Treatment Planning Procedures have been initiated on both 2 North and 2 West to ensure that treatment plans are updated within the specified timeframes of Cermak policy. The “Treatment Plan CQI” looks at treatment plans for P4’s since the last site visit. The overall compliance percentage of 95% suggests that consistency has been maintained in terms of the development, review, and updating of treatment plans. Continued assessment of quality and effectiveness of the treatment plan should continue during the next reporting period to better understand the impact our services have on our patients’ mental health and wellbeing. The treatment plan audit and summary will be provided in a separate Appendix document analyzing treatment plans across the department.
Additional Activities In addition to providing assessment/treatment planning, milieu therapy, rounds, individual sessions, and group sessions, the mental health staff also meets daily in a “morning huddle” to discuss new admissions and any concerns or questions from the previous day(s). Staff will also regularly engage in multidisciplinary treatment team meetings held twice per week on both units to discuss patient progress, update the patients’ treatment plans, and address any other pertinent items/issues. The restraint and seclusion log for the previous week is reviewed weekly during staffing, and staff is given the opportunity to discuss any issues or questions they have with the process of utilizing therapeutic restraint/seclusion. Multidisciplinary Treatment Team (MDT) meetings are scheduled regularly and invited parties include psychiatrists, psychologists, physician’s assistants, mental health specialists, nurses, and correctional officers. With regards to the milieu and therapeutic environment on the psychiatric special care units, staff work towards developing rapport with each patient and providing a sense of physical and emotional safety. This is especially the case on 2 West (females), where staff provides a more trauma-informed approach to working with patients. Staff encourages patient compliance with treatment while also respecting patients’ rights. Patients are assessed upon admission to the units by licensed mental health staff, as well as prior to discharge.
The daily incentive program is utilized on 2 West to encourage patients to participate in healthpromoting activities, such as hygiene, group therapy, medication compliance, and displaying safe and appropriate behaviors. Mental health staff modify the incentive program for patients with special circumstances (such as out alone/house alone status) to make it possible for all patients to participate in the program.

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An ongoing area of improvement is cooperation/collaboration across disciplines. This has traditionally been a challenge, but has been moving in a positive direction. Mental health specialists are more likely to communicate/collaborate with medical, nursing, and the officers. This collaboration can be challenging at times due to discrepancies between professional perspectives and opinions. We will continue to hold multidisciplinary clinical staffings to ensure that all disciplines are represented and that all varying perspectives are taken into account.
Improvement since 5/29/17 (2W, 2N, UC): 1. Increased quantity of small group room programming, thereby increasing the quality of mental health treatment provided. On average, 2W patients received 5 small groups per week (mental health and expressive arts) and 2N patients received 3 small groups per week. 2. Increased adherence to treatment plan policy (overall compliance 95%). 3. The 2W incentive plan has been revamped. The incentive plan has been simplified for staff and patients. The incentives are earned daily so patients receive timely cause and effect feedback. Incentives are focused on promoting hygiene and self-esteem (deodorant, scented lotion, and socks), contact with loved ones (stamped envelope), prosocial group activities (movie day, coloring sheets), and positive coping, and food incentives. 4. MDT staffing notes are now entered in patient charts to reflect the multidisciplinary team discussion to promote effective communication regarding patient progress and future treatment goals. 5. A specialty Cerner list was developed for patients in need of sleep monitoring as well as a sleep log. Sleep monitoring assists staff with monitoring symptoms in real time Psychiatrists, psychologist, and mental health specialists have access to the list. The midnight shift mental health staff routinely monitor the list and document hourly sleep habits of patients on the list. 6. In the past, bed space was problematic due to discharged patients remaining on the unit. This delay resulted in lack of bed space for newly admitted patients and increased acting out behaviors from discharged patients. Since the last site visit, the unit director sent daily movement lists to CCDOC classification and Cermak movement to ensure rapid movement of discharged patients. The wait time for discharges decreased significantly from approximately 3 days to less than 6 hours, resulting in admissions spending less time waiting in the urgent care for a bed. 7. The expressive therapist facilitated mural painting groups. The unit murals provide a vibrant, uplifting environment. The patients are able to express their feelings in a therapeutic manner and feel proud of the contribution made to the unit. 8. More aggressive and disruptive patients can spend more time out-of-cell with the installation of secured television sets and secured ‘watching stations’ in the hallway. 9. Due to the increased number of chronically mentally ill patients, hygiene issues remain a concern and are reflected as needed in treatment plans. Humanitarian showers are routinely occurring to promote improved personal hygiene and sanitary conditions on the

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unit. 10. There has been a strong effort by Psychiatry to increase the number of cases petitioned
for involuntary court-ordered medications. 11. The number of patients P&C when released from CCDOC custody continues to rise
(average of 2 per week). Patients are more readily identified by adding names to the Cerner P&C list after the morning huddle, which is reviewed prior to each P4 patient being released from custody
Areas Needing Improvement: 1) Continue improving multidisciplinary communications and a team-oriented approach to treatment. 2) Continue to regularly evaluate group quality through conducting random structured evaluations and providing feedback to mental health staff. 3) Improve the quality of documentation by mental health staff, specifically group notes and comprehensive, individualized treatment plans for the acute population. 4) New treatment materials would be beneficial, particularly for lower functioning, chronically/ seriously mentally ill patients. 5) A monetary budget for the incentive program is needed in order for it to remain robust and with a variety of available incentive items.
2 South, 2 Southeast, and 2 East serve as step-down units for 2 North patients who are in need of longer term care. 2 South has 17 beds, including three four-person rooms, and serves as a mainstream male psychiatric unit. 2 Southeast and 2 East are smaller units serving more specialized populations. 2 Southeast has nine beds, all in single housing, and serves patients who are more severely psychiatrically impaired (often refusing treatment), with recent histories of aggression against staff or other detainees. Patients on this unit generally cannot be managed in other settings, and may be under consideration for petitioning for involuntary court ordered medications. 2 East is a 12 bed unit with a mix of individual and four-person rooms, and serves as a chronic care setting for the most fragile patients, often older individuals with cognitive impairments, in a protective setting.
All units are staffed with 24-hour nursing care, fulltime mental health staff on two shifts and a midnight shift staff member covering the floor, and fulltime psychiatry, physician assistant, psychology, and medical social work services.
The 2 South offers up to eight hours of structured group programming and unstructured dayroom activity per day, seven days per week. Due to current staffing allocations, 2 East currently offers group programming on one shift per day. ; As additional staff are hired programming will be expanded to the evening shift. Patients housed on 2 Southeast who are able to participate in group programming and milieu activities join these events on 2 South. 2 Southeast patients who are not able to tolerate the stimulation of group activity are given individual time out alone or in twos or threes. Some patients require restraint when in the dayroom to ensure safety of others.

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Programming includes daily ‘Rise and Shine’ group, a morning hygiene group, Community Meeting, Medication Management Group, Coping Skills, Anger Management, Current Events, Art Therapy, and Community Reintegration, Chair Yoga, and other topics. Daily scheduling of programming follows the same timeframe as that of 2 North and 2 West. As on 2 West, all three male units utilize the incentive program to promote participation in hygiene, group programming, and compliance with medications.
Developments in the Last 6 Months
1. Separation of 2 Southeast from 2 South has continued to promote a more therapeutic milieu on both units. More aggressive and disruptive patients have been better managed in the smaller, less stimulating environment of 2 Southeast. In addition, modifications have been made to the physical plant to promote safety. Aggressive, highly impulsive patients can spend more time out-of-cell with the installation of secured television sets and secured ‘watching stations’ in the dayroom. 2 South patients are able to participate in programming with reduced risk of disruptive, aggressive, or predatory behavior by more severely impaired, treatment-refusing individuals.
2. There has also been increased effort to ensure that all court-discharged patients who meet criteria for involuntary admission by petition and certificate for continued treatment in an area hospital are sent by ambulance when released. In the past four years, we have averaged about 50 patients per year. This year, we expect to send about 75 patients to the hospital for involuntary admission on petition and certificate.
3. Recent hiring of additional Mental Health Specialist positions has provided seven-day coverage on 2 East for day shift and eliminated the need to ‘pull’ staff to provide needed coverage when staff members call in sick. Hiring of additional MHSs is expected to provide fulltime evening shift coverage for 2 East as well.
4. We have worked with Ferguson Safety Products to design a safety jumpsuit which is more dignified, durable, and tamper resistant. We have used several prototypes with our patients to beneficial effect. In addition, beds on the units are being replaced by newer and safer ‘moduform’ beds.
5. Along with the newer model ‘moduform’ beds, we have switched to newer model polypropylene restraints to replace the old leather restraints. The new restraints are easier to use, safer, and easier to clean. All Cermak nursing and mental health staff have been trained in the use of the new restraints.
6. With these improvements in staffing and the physical milieu, there have been increases in programming hours, staff and patient safety, and successful management of the most severely mentally ill patients in the CCDOC system. This has meant that patients can be maintained in Cermak with less movement off-tier due to extreme disruptive and

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aggressive behavior. Overall we are increasingly more successful in managing and stabilizing our most challenging patients.
Detainees meeting criteria for involuntary admission by petition and certificate are transported to one of two area hospitals (Mt. Sinai and St. Anthony) upon release from Cermak by the court system. All detainees with P4 alert are evaluated at the moment of court release, and those anticipated to meet criteria for involuntary admission in the community are also ‘flagged’ ahead of time in EMR to ensure that their need for continued inpatient treatment is not overlooked if they are released in the overnight hours. There has been no indication of ‘missed’ evaluations at discharge recently, and the program continues to be efficient.

INVOLUNTARY HOSPITALIZATION BY PETITION & CERTIFICATE UPON RELEASE 2014-17

YEAR Q1

Q2

Q3

Q4 TOTAL

2017

16

18

21

55

2016

10

13

11

15

49

2015

12

15

5

13

45

2014

12

13

11

11

47

Detainees meeting criteria for the administration of involuntary medications (non –emergency basis) continue to be evaluated for filing of the Petition. Some patients refuse to accept psychotropic medications, sometimes even in cases when their safety and survival depends on their receiving treatment. In those cases, judges are petitioned to authorize involuntary treatment. Typically our petitions for the administration of involuntary treatments are heard by the judges at the Circuit Court of Cook County. Cermak's petitions for the involuntary administration of psychotropic medications undergo vigorous judicial review and are not afforded the administrative review process. Following a Circuit Court Resolution permitting the use of Teleequipment to conduct court hearings from remote sites, Circuit Court Judges began conducting hearing remotely, allowing respondents, lawyers, witnesses, and Psychiatrists to be present at the Leighton Center, which substantially reduced Cermak’s travel and time expenditures. Additionally, in order to improve efficiency and continuity of care between Department of Mental Health Facilities where detainees are remanded for the restoration of fitness, a reciprocal process has been developed, allowing for the modifications of Court Orders for Involuntary Medications ( nonemergency basis) to other counties when detainees leave CCDOC campus for DMH facilities and, conversely, detainees returning from DMH following the restoration of fitness have their court orders for involuntary medications “domesticated” to Cook County. The CCHHS Office of General Counsel has been responsive to Cermak’s needs and coordinated various aspects of the

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said process. There has been an increase in petitions filed, as compared with other years. The table before summarizes some of the recent trends.

COUNT

INVOLUNTARY MEDICATIONS/AOT BY YEAR
25

20

15

10

5

0 2012

2013

2014

2015

YEAR

2016

2017

Involuntary medications by court order( nonemergency basis)/AOT petitions FILED/ORDERED [QUARTERLY
2014-17]

YEAR Q1 Q2 Q3 Q4 TOTAL

2017

6/3 7/7 10/4

23/17

2016

3/2 1/1 3/3 7/6 14/12

2015

3/1

1/1 1/1

2/2 7/5

2014

1/1

2/1 1/1

2/2 6/5

Cermak periodically updates CCDOC Leadership on complex management cases. CCDOC Leadership discusses these cases with ASA and the Office of PD Leadership trying to establish priorities in streamlining cases and coordination between multiple parties. Cermak PCC and MH files petitions for Guardianship, when needed. CCHHS Office of general Counsel assists in gathering information and setting up hearings.

AOT (Assisted Outpatient Treatment, a.k.a Outpatient Commitment): CCHHS received a SAMSHA grant for the implementation of the AOT program. 4-year pilot program is intended to implement and evaluate new AOT programs and identify evidence-based practices in order to reduce the incidence and duration of psychiatric hospitalization, homelessness, incarcerations, and interactions with the criminal justice system while improving the health and social outcomes of

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individuals with a serious mental illness (SMI). Various part of the CCHHS, ASA, Guardianship and Advocacy Commission, Judiciary, and local community mental health centers collaborate. Cermak Chief of Psychiatry is on the CCHS AOT steering committee. This program is designed to work with families and courts, to allow these individuals to obtain treatment while continuing to live in the community and their homes. AOT is intended to facilitate the delivery of communitybased outpatient mental health treatment services to individuals with SMI that are under court order as authorized by state mental health statutes. Cermak staff assists Project Advisors and Project Managers in identifying and vetting potential AOT candidates. Providers file Petitions and Certificates for AOT with court and attend hearings. The treatment aspect of the AOT petition is similar to the traditional Involuntary Medication Petition by court order (nonemergency basis). AOT agreements/court orders compel detainees with SMI previously known for noncompliance with outpatient and inpatient treatment, comply with outpatient treatments in the community. Detainees are rehospitalized, and not re incarcerated, when compliance with AOT treatments is breached. It is emphasized that the AOT program is not a diversion program and the outcome of AOT hearings has no bearing on their criminal cases.
The Medical Social Workers also continue to be an integral part of the response to calls received by the Sheriff’s Care Line. All information related to mental health issues continues to be forwarded to the identified medical social workers for follow up and/or delegation to divisional social workers if indicated. Since the last visit, our social work staff has addressed 40 calls/referrals. Of those referrals, (73%) had already been identified, evaluated, placed on the MH caseload and were receiving treatment. None of the referrals yielded new additions to the MH caseload or yielded information that Cermak providers did not yet have access to, and the remaining (27%) referrals were determined to not be in need of continued follow up from the MH department. This collaborative community outreach effort contributes to access to collateral information and opportunity for improved care and clarification of needs.
November 2017 Metzner assessment: The significant improvements in the therapeutic milieu noted during the previous site assessment have been maintained and the numbers of hours of structured out of cell therapeutic activities being offered to detainees in the PSCU has increased.
During the morning of November 13, 2017, I observed therapeutic activities occurring on each of the housing units within the PSCU. Detainees were actively participating in these groups.
I also attended morning huddles for Units 2W and 2N during November 14, 2017. During the afternoon of November 14, 2017, I observed a treatment planning meeting on Unit 2W, which was attended by all the appropriate staff with very good multidisciplinary input. As in the past, clinical staff observed were very competent in performing their tasks.

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Recommendations: Continue to self-monitor.
m. Cermak shall provide the designated CCDOC official responsible for inmate disciplinary hearings with the mental health caseload roster listing the inmates currently receiving mental health care. (included in this Appendix for formatting purposes only)
Assessment: Substantial compliance (since June 2012) n. When CCDOC alerts Cermak that an inmate is placed in lock down status for disciplinary reasons, a Qualified Mental Health Professional will review the disciplinary charges against inmate to determine the extent to which the charge was related to serious mental illness. The Qualified Mental Health Professional will make recommendations to CCDOC when an inmate’s serious mental illness should be considered as a mitigating factor when punishment is imposed on an inmate with a serious mental illness and to minimize any deleterious effect of disciplinary measures on an inmate’s mental health status.
Assessment: Substantial compliance continues (since October 2012). (included in this Appendix for formatting purposes only)
o. Cermak 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.
p. Cermak shall ensure that inmates have access to appropriate acute infirmary care, comparable to in-patient psychiatric care, within the Cermak facility.
Compliance Assessment: Substantial compliance (6/17)
Factual Findings:
November 2017 Cermak Status Update
There has been tremendous improvement in the response to and compliance with timeliness in responding HSRF since the last site visit. The approved revision to pertinent policy and procedure has been the main driver of these improvements. Additionally, increased staffing and resulting increased number of available clinics to respond to requests has positively influenced compliance. Please see PDF Appendix for expanded QI.

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 66 of 86

NonUrgent HSR

JUNE 2017 JULY 2017 AUGUST 2017

Compliance Patients Seen

95.60% 98.11%

94.57%

Timeliness Patients Seen on Time 87.47% 88.45%

88.37%

Urgent HSR Compliance Timeliness

JUNE 2017 JULY 2017 AUGUST 2017

Patients Seen

97.92% 100.00%

97.67%

Patients Seen on Time 89.58% 94.34%

88.37%

November 2017 Metzner assessment: My April 2016 assessment included the following: QI data documents issues in meeting timelines for responses to routine mental health referrals related to the current policy and procedure that requires a face to face triage for routine referrals within 72 hours and periodic delays in receiving the referral from nursing staff in a timely manner. I discussed with staff potential revisions to the pertinent policy and procedure that will significantly decrease the lack of compliance. In addition, the process involved with the sending of the mental health referrals from the nursing staff to mental health services needs to be improved.

Specifically, it remains my recommendation that timeframes for HSRFs specific to mental health services that have been triaged as routine referrals be changed to and appropriate clinical mental health response to 10 business days.

The above recommendations were implemented during June 2017. Scheduling issues were directly related to the 12% of nonurgent HSR’s not meeting required timeframes, which have subsequently been corrected. Compliance since June 2017 is noted.

Recommendations: Repeat the QI relevant to this provision.

60. Psychotherapeutic Medication Administration
c. Cermak shall ensure that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis for appropriateness or adjustment. Cermak shall ensure that changes to an inmate’s psychotropic medications are clinically justified and documented in the inmate’s medical record.
d. Cermak shall ensure timely implementation of physician orders for medication and laboratory tests. Cermak shall ensure that 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.

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Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 67 of 86

Compliance Assessment: Substantial compliance (4/17)

Factual Findings:

November 2017 Cermak Status Update

As

of

10_05_2017

Lithium

Divalproex

Sodium/

Valproic Acid

Risperidone/

Ziprasddone/

Olanzapine

# of Orders

Medication 23 156 526

# of Laboratory Orders
23
154
509

Compliance rate
100.00%
98.72%
96.77%

Periodic monitoring of blood levels of Lithium and Depakote is important for the safe administration of the said medications. It is suggested that blood levels are checked at least every 6 months, even if a patient remains asymptomatic and the dosage remains unchanged. A new Cerner alert continues to prompt Providers if medication level check is due (If no Li and VPA levels had been ordered over the past 6 months, it prompts to order Li, and VPA levels). Similarly, the new rule automatically fires with the tests for Non-fasting Lipids, Hb A1C, and weight measurement, if the said tests had not been performed over the past 6 months. As demonstrated by the chart, the frequency of medication monitoring has reached levels well above 90%.
Critical Medications Missing Alert functions in Cerner. A list of patients who have missed 2 or more critical meds in the last 7 days is generated (including Clozapine and long acting Decanoate/Consta formulations). This report triggers a request for review by Providers. Additionally, Nurses report refusal of three or more doses to the provider and followed by a eMERS (patient care/safety report).
Prescription of Diphenhydramine and similar antihistamine medications, when prescribed for idiopathic insomnia, is limited to one time prescription to 2 weeks’ worth of the medicine ( unless detainees are prescribed these medications to alleviate medications’ side effects) followed by the Sleep Hygiene training conducted by Mental Health Specialists.
Neuroleptic polypharmacy reflective of providers’ practice has been studied. Polypharmacy rates are below of what is expected in the community setting. Please refer to Polypharmacy in Severe Mental Illness and Antipsychotic Polypharmacy QI studies in the APPENDIX.

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 82 of 86 PageID #:5749 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 68 of 86 November 2017 Metzner assessment: As per update section. Substantial compliance continues. Recommendations: Continue to monitor via QI studies.
Appendix V

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Please have the following information available in hard copy at the time of the site visit, and sent to me one week prior to the site visit in electronic form (but not in PDF) unless indicated otherwise. Each piece of information should cover the period since the last site visit.

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 84 of 86 PageID #:5751 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 70 of 86
Note: If any of the requests are too burdensome to produce, please contact me before attempting to produce such information.
Appendix I Agreed Order 5/13/10 MH provisions revised
Using the word version of Appendix IV in my last submitted report, after each of the “recommendations” section add the following section: April 2018 Cermak status update: and complete a narrative with proof of practice as available. This document request is the most crucial document. Please do not delete my November 2017 findings or recommendations except for provisions that have been found in substantial compliance for at least 18 months.
Some of the following requests may be in the above document and only need to be referenced—it does not have to be provided twice.
Mental Health System
1. The mental health system organization chart (with both position and name of person filling the position and his/her credentials- e.g., degree).
2. Any new policies and procedures relevant to mental health services.
3. Any new program descriptions of the current mental health system.
4. Any other reports (i.e., internal or external reviews) relevant to the mental health system at CCDOC.
Institutional Program Status
1. Narrative summary of program status
Staffing
1. List authorized mental health staff positions by discipline (psychiatrists, psychologists, social workers, nursing staff, clerical staff, etc.) and by program/area (intake, crisis stabilization, mental health housing units, etc.). For each position, indicate the person’s name, professional degree, start date, and percent of FTE if not full-time. If the position

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 85 of 86 PageID #:5752 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 71 of 86
is vacant, provide the date it became vacant. For any staff on leave, indicate the date the leave began.
2. List any newly allocated mental health positions and the dates they were established.
Census/Mental Health Roster
1. The total number of inmates in the jail, total number in segregation units, total number of mental health caseload inmates, and total number of inmates in each program area (crisis observation, mental health housing, general population, etc.).
2. Statistical information pertinent to the reception center screening of inmates (i.e., number of persons on a daily, weekly, or monthly basis for the past six months, percentage of inmates who have positive screens from a mental health perspective, percentage of inmates with positive screens who enter the continuum of mental health services, percentage of all newly admitted inmates who enter the continuum of mental health services).
Quality Improvement
1. A copy of each relevant QA/QI audit conducted, preferably in electronic forms. For each audit provided, a description of:
a. Statement of the issue being studied b. Methodology used c. Results d. Assessment of results e. Plan of action based on the assessment
Suicide Prevention
1. For any completed suicide, a copy of the mortality and review report.
Additional Items
1. Schedule of group therapies/structured out of cell therapeutic activities offered to inmates in the mental health housing units.*
2. Logs showing the use of restraints and seclusion, including the dates and times the orders were initiated, renewed, and discontinued, and the timing of nursing checks conducted.*

Case: 1:10-cv-02946 Document #: 369 Filed: 05/03/18 Page 86 of 86 PageID #:5753 Re: Mental Health Services at CCDOC USA v Cook County, et al. Page 72 of 86
*Does not need to be sent in advance of site visit.

 
 Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 1 of 49 PageID #:5810
Cook County Jail Sixteenth Monitoring Report
by Esmaeil Porsa, MD, MBA, MPH, CCHP-P, CCHP-A
May 2018

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 2 of 49 PageID #:5811
EXECUTIVE SUMMARY During the week of April 30, 2018, the Medical Monitoring Team (Monitoring Team)
visited Cook County Jail. The team included: Esmaeil Porsa, MD, MBA, MPH, CCHP-P, CCHP-A, Muthusamy Anandkumar, MD, MBA, Madeleine LaMarre FNP-BC, and Linda Pansulla, RN, MBA, CCHP. The Monitoring Team visited several of the Cook County Jail medical facilities and housing units. We also interviewed various Cermak and Cook County Department of Corrections (CCDOC) leadership and front line staff as well as Cook County Jail inmates. We extend our most sincere thanks to all the Cermak and CCDOC leadership and staff for their hospitality and generosity with their time and resources. We additionally thank Cermak and CCDOC leadership and staff for their openness to the Monitoring Team suggestions and our critical appraisal of Cermak’s processes and activities over the past six months. Cook County Jail Cermak and CCDOC personnel were completely cooperative and helpful in this monitoring visit. The Monitoring Team enjoyed full and unhindered access to all areas and staff.
All provisions of medical care have sustained substantial compliance since our last visit in November 2017. Of note, the timely access to medical and dental care for urgent conditions has been addressed. We were able to sample a large number of routine and urgent medical and dental sick call requests and verify that in almost all instances face to face nurse sick call encounters are occurring on the same day or the following day after a sick call request has been submitted. Similar to our previous visits, we were able to identify recurring and new best in class activities at Cermak. These include infection prevention, OB care, detox care, intake screening (previously mentioned) as well as dental care and sick call electronic dashboard (newly recognized). We will more fully recognize these achievements in the body of this report.
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Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 3 of 49 PageID #:5812 As discussed in our exit meeting, the Monitoring Team would like to congratulate
Cermak and CCDOC for their continued commitment to maintaining a robust and functional partnership that is with no doubt one of the main reasons for the continued success and efficacy of both entities in the provision of correctional health care services in a safe environment. We hope that this partnership is sustained. Considering the current status of Cermak with regard to the continued substantial compliance with all the provisions of the agreed order and Cermak’s proven desire and knowhow of continuing down the path of a high reliability organization, the Monitoring Team would like to unanimously recommend that medical monitoring of the Cook County Jail be brought to conclusion. We would like to congratulate Cermak leadership and the front line staff for this momentous achievement.
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Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 4 of 49 PageID #:5813
Introduction and Report Organization On Monday April 30, 2018, the population of Cook County Jail was reported as 5,988.
There were another 2,068 inmates listed under “Community Corrections Population” bringing the total under custody population to 8,056. This was the lowest census at Cook County Jail since this Monitoring Team began visiting Cermak four years ago. Definitions and Organization
This report is formatted in the manner requested by the Department of Justice and closely follows the Agreed Order. The report includes four parts for each section of the Agreed Order.
In part one; we rewrite verbatim the pertinent portion of the Agreed Order. This first part is labeled Remedial Measure of Agreed Order.
The second part is the overall compliance rating labeled Compliance Assessment. This is the assessment that the Monitoring Team experts make based on judgment, data, and chart reviews. Throughout this Agreed Order, the following terms are used when discussing compliance: substantial compliance, partial compliance, and non-compliance: “Substantial Compliance” indicates that the relevant Defendant(s) has achieved compliance with most or all components of the relevant provision of the Agreed Order. “Partial Compliance” indicates that compliance has been achieved on some of the components of the relevant provision of the Agreed Order, but significant work remains. “Non-compliance” indicates that most or all of the components of the Agreed Order provision have not yet been met. Non-compliance means that much work needs to be done before compliance is met. When indicated, the Monitoring Team will additionally assess the various components (sub-bullet points) of certain sections of the Agreed Order. Our goal is to highlight areas of success and bring focus to areas that need further refining and attention.
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Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 5 of 49 PageID #:5814 The third part is the factual basis for forming the opinion in the Compliance Assessment.
This will be as data driven as possible. For patient care areas, chart reviews form a substantial portion of this review. Touring, interviews, and reviewing data sources is also an important means of making assessments.
The fourth part is our recommendations. These recommendations are our view of what needs to be accomplished to attain and maintain compliance. This will include the Monitoring Team’s recommendations for self-monitoring activities and audits.
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HEALTH CARE SERVICES: ELEMENTS COMMON TO MEDICAL AND MENTAL HEALTH 41. Inter-Agency Agreement
a. CCDOC shall enter into a written Inter-Agency Agreement with Cermak that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
b. Cermak shall enter into a written Inter-Agency Agreement with CCDOC that delineates the mutual responsibilities of each party, relative to the provision of health care to inmates at the Facility. The Inter-Agency Agreement shall be finalized within 60 days of the effective date of this Agreed Order.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Monitor’s Findings:
Spot checking showed no lapses in compliance. Monitor’s Recommendations:
None. 42. Policies and Procedures
Cermak shall provide adequate services to address the serious medical and mental health needs of all inmates, in accordance with generally accepted professional standards. The term “generally accepted professional standards” means those industry standards accepted by a
6

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 7 of 49 PageID #:5816
majority of professionals in the relevant field, and reflected in the standards of care such as those published by the National Commission on Correctional Health Care (“NCCHC”).
a. Cermak shall develop and implement medical care policies, procedures and practices to address and guide all medical care and services at the Facility, including, but not limited to the following: i. access to medical care ii. continuity of medication iii. infection control iv. medication administration v. intoxication and detoxification vi. documentation and record keeping vii. disease prevention viii. sick call triage and physician review ix. intake screening x. chronic disease management xi. comprehensive health assessments xii. mental health xiii. women’s health xiv. quality management xv. emergent response xvi. infirmary care xvii. placement in medical housing units
xviii. handling of grievances relating to health care
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Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 8 of 49 PageID #:5817
xix. mortality review xx. care for patients returning from off-site referrals c. Cermak shall develop and implement policies, procedures and practices to ensure timely responses to clinician orders including, but not limited to, orders for medications and laboratory tests. Such policies, procedures and practices shall be periodically evaluated to ensure timely implementation of clinician orders. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot check monitoring as indicated. Monitor’s Findings: Spot checking showed no lapse in compliance. Monitor’s Recommendations: None. 43. Medical Facilities a. CCDOC will work with Cermak to provide sufficient clinical space, as identified by Cermak staff, to provide inmates with adequate health care to meet the treatment needs of detainees, including: intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. b. Cermak shall make known to CCDOC and Cook County its needs for sufficient clinical space, with access to appropriate utility and communications capabilities, to provide inmates with adequate health care to meet the treatment needs of inmates including:
8

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 9 of 49 PageID #:5818
intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. c. Cook County shall build out, remodel, or renovate clinical space as needed to provide inmates with adequate health care to meet the treatment needs of detainees as identified by Cermak staff including: intake screening; sick call; medical and mental health assessment; acute, chronic, emergency and specialty medical care (such as geriatric and pregnant inmates); and acute, chronic and emergency mental health care. d. Cermak shall ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in examination rooms. Cermak shall ensure that hand washing stations in medical care areas are fully, equipped, operational and accessible. e. Cermak shall ensure that appropriate containers are readily available to secure and dispose of medical waste (including syringes and medical tools) and hazardous waste. f. CCDOC shall allow operationally for inmates reasonable privacy in medical and mental health care, and shall respect the confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically includes sight and hearing privacy from other inmates, and hearing privacy from staff that are not providing care. g. Cermak shall make known to CCDOC and Cook County the structural and operational requirements for inmates’ reasonable privacy in medical and mental health care. Cermak shall provide operationally for inmates’ reasonable privacy in medical and mental health care and shall respect the confidentiality of inmates’ medical status, subject to legitimate security concerns and emergency situations. Reasonable privacy typically includes sight
9

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 10 of 49 PageID #:5819
and hearing privacy from other inmates, and hearing privacy from staff that are not providing care. h. Cook County shall build out, remodel or renovate clinic space as needed to allow structurally for inmates’ reasonable privacy in medical and mental health care, as identified by Cermak and CCDOC staff. i. Cook County shall begin construction of the new clinical space within 3 months of the effective date of this Agreed Order. It is expected that the project will be completed within nine months of the effective date of this Agreed Order. Prior to the completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding clinical space, to the extent possible in the current facility. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such is no longer being monitored except for spot check monitoring as indicated. Monitor’s Findings: Spot checking showed that medical facilities remain in substantial compliance. Monitor’s Recommendations: Sustain improvements in clinic organization and sanitation. Ensure that environmental cleaning takes place as scheduled in the Divisions and Cermak administrative areas. 44. Staffing, Training, Supervision and Leadership
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a. Cermak shall maintain a stable leadership team that clearly understands and is prepared to move forward toward implementation of the provisions of this Agreed Order, with respect to: i. Medical care; and ii. Mental health care
b. Cermak shall maintain an adequate written staffing plan and sufficient staffing levels of health care staff to provide care for inmates’ serious health needs, including: i. Qualified Medical Staff; and ii. Qualified Mental Health Staff.
c. Cermak shall ensure that all Qualified Medical Staff and Qualified Mental Health Staff are adequately trained to meet the serious health care needs of inmates. All such staff shall receive documented orientation and in-service training on relevant topics, including: i. Provision of health care in a correctional setting and Facility-specific issues; and ii. Suicide prevention, and identification and care of inmates with mental illness.
d. Cermak shall ensure that Qualified Medical Staff receive adequate physician oversight and supervision.
e. Cermak shall ensure that all persons providing health care meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure. Upon hiring and annually, Cermak shall verify that all health care staff have current, valid, and unrestricted professional licenses and/or certifications for: i. Medical staff; and ii. Mental health staff
11

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f. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on recognition and timely referral of inmates with medical urgencies, including drug and alcohol withdrawal. Cermak will provide adequate initial and periodic training on these topics to all Cermak staff who work with inmates.
g. CCDOC will provide, to all CCDOC staff who work with inmates, adequate initial and periodic training on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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.
h. Cermak will work with CCDOC to develop and maintain a curriculum for initial and periodic training of correctional officers on basic mental health information, including the identification, evaluation, and custodial care of persons in need of mental health care, as well as 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.
i. Cermak shall ensure that all health care staff receive adequate training to properly implement the provisions of this Agreed Order, including:
12

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 13 of 49 PageID #:5822
a. Medical staff; and b. Mental health staff. Compliance Status: This provision remains in substantial compliance. Monitor’s Findings: 1. Since our last visit in November 2017, Cermak has lost its Director of nursing as well as several nurse managers. While the overall vacancy rate stands at 16%, the vacancy rate for staff physician in the medical area is at 40%. The Monitoring Team was assured that within the next three months at least four new physicians including graduating residents will be on boarded. This will dramatically reduce the overall medical physician vacancy from 40% to 20%. Additionally, the census of Cook County Jail is at a historic low for the duration of our monitoring engagement thus negating any potential negative impact of physician vacancy. Additionally, we did not identify any gaps in the provision of medical care related to physician vacancy. System wide, there has been a net gain of 2 new staff positions. 13 new staff positions have been created including two Quality Assessment Coordinators, seven case managers and four case workers. 11 staff positions were eliminated. Since November 2017, there have been 35 new hires and 44 new vacancies (transfers, resignations, retirements, terminations, etc.). The overall vacancy rate across Cermak is currently at 16% or 108 total vacancies (576 out of 684 total positions filled). There is one Advanced Practice Provider (PA) and eight Attending physician position vacancies. Patient Care Services including nursing vacancy now stands at 15%. Cermak continues to utilize overtime, contract labor (moonlighting, locums, etc.) and part time staffing to meet their provision of health service needs.
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2. The Monitoring Team did not review the annual training, Ongoing Professional Practice Evaluation (OPPE) or the credentialing files of Cermak professional staff since this provision has been in substantial compliance for more than 18 months.
3. We did not review ongoing initial and interval training of CCDOC officers as this provision has been in substantial compliance for more than 18 months.
4. While the Monitoring Team is encouraged about the continued drop in the inmate census at the Cook County Jail, we remain vigilant that staffing and processes of care at the jail continue to meet the needs of the detainee population.
Monitor’s Recommendations: 1. We strongly recommend that Cermak remains vigilant on filling nursing and staff physician vacancies to further improve the provision of health care as well as to reduce the utilization of overtime and contract labor. 2. Maintain/improve vacancy rate across the system but especially in nursing leadership.
45. Intake Screening a. Cermak shall maintain policies and procedures to ensure that adequate medical and mental health intake screenings are provided to all inmates. b. Cermak shall ensure that, upon admission to the Facility, Qualified Medical Staff or Licensed Correctional Medical Technicians utilize an appropriate medical intake screening instrument to identify and record observable and non-observable medical needs, shall assess and document the inmate’s vital signs, and shall seek the inmate’s cooperation to provide information, regarding:
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Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 15 of 49 PageID #:5824
(1) medical, surgical and mental health history, including current or recent medications, including psychotropic medications;
(2) history and symptoms of chronic disease, including current blood sugar level for inmates reporting a history of diabetes;
(3) current injuries, illnesses, evidence of trauma, and vital signs, including recent alcohol and substance use;
(4) history of substance abuse and treatment; (5) pregnancy; (6) history and symptoms of communicable disease; (7) suicide risk history; and (8) history of mental illness and treatment, including medication and
hospitalization. c. Cermak shall ensure that, upon admission to the Facility, Qualified Mental Health
Staff, Qualified Medical Staff, or Licensed Correctional Medical Technicians utilize an appropriate mental health intake screening instrument to identify and record observable and non-observable mental health needs, and seek the inmate’s cooperation to provide information, 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;
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(5) previously identified suicide risk during any prior confinement at CCDOC; (6) any observations of the transporting officer, court, transferring agency or
similar individuals regarding the inmate’s potential suicide risk, if such information is communicated to Cermak staff; (8) psychotropic medication history; and (9) alcohol and other substance use and withdrawal history. d. Cermak shall ensure that all Qualified Mental Health Staff, Qualified Medical Staff or Licensed Correctional Medical Technicians who conduct the medical and mental health intake screenings are properly trained on the intake screening process, instrument, and the requirements and procedures for referring all qualifying inmates for further assessment. e. If Cermak assigns Licensed Correctional Medical Technicians to perform intake screening, they shall receive appropriate, on-site supervision by on-site Qualified Medical Staff; information obtained on screening for all inmates will be reviewed by Qualified Medical Staff before the inmate departs the intake area. f. Cermak shall ensure that a medical assessment based on the symptoms or problems identified during intake screening is performed within two working days of booking at the Facility, or sooner if clinically indicated, by a Qualified Medical Professional for any inmate who screens positively for any of the following conditions during the medical or mental health intake screenings: (1) Past history and symptoms of any chronic disease included on a list specified by Cermak’s policies and procedures;
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(2) Current or recent prescription medications and dosage, including psychotropic medications;
(3) Current injuries or evidence of trauma; (4) Significantly abnormal vital signs, as defined by Cermak’s policies and
procedures; (5) Risk of withdrawal from alcohol, opioid, benzodiazepine, or other substances; (6) Pregnancy; (7) Symptoms of communicable disease; and (8) History of mental illness or treatment, including medication and/or
hospitalization. g. Cermak shall ensure that any inmate who screens positively for mental illness or
suicidal ideation during the intake process receives a comprehensive mental health evaluation (see provision 59.c, “Mental Health: Assessment and Treatment”) Cermak shall ensure timely access to a Qualified Mental Health Professional for this purpose, based on emergent, urgent, and routine medical or mental health needs. h. Cermak shall ensure that the intake health screening information is incorporated into the inmate’s medical record in a timely manner. i. Cermak shall implement a medication continuity system so that incoming inmates’ medication for serious medical and mental needs can be obtained in a timely manner, as medically appropriate. Within 24 hours of an inmate’s booking
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at the Facility, or sooner if medically necessary, a Qualified Medical Professional or Qualified Mental Health Professional, with appropriate prescribing authority, shall decide whether to continue the same or comparable medication for serious medical and mental health needs that an inmate reports during intake screening that she or he has been prescribed. If the inmate’s reported medication is discontinued or changed, other than minor dosage adjustments or substitution of a therapeutic equivalent, a Qualified Medical Professional or Qualified Mental Health Professional, with appropriate prescribing authority, shall evaluate the inmate face-to-face as soon as medically appropriate, and within no greater than five working days, and document the reason for the change. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such is no longer being formally monitored except for spot check monitoring as indicated. Monitor’s Findings: Spot checking showed that this area remains in substantial compliance. Monitor’s Recommendations: 1. Cermak leadership should continue periodic CQI studies assessing the appropriateness, timeliness and quality of care. 2. The QI program should continue to monitor the documentation of timely receipt of medications that are deemed critical. 46. Emergency Care
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a. Cermak shall train health care staff to recognize and respond appropriately to health care emergencies, including: (1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
b. CCDOC shall train correctional officers to recognize and respond appropriately to health care emergencies, including: (1) Medical emergencies; (2) Mental health emergencies; and (3) Drug and alcohol withdrawal.
c. CCDOC shall ensure that all inmates with emergency health care needs receive prompt transport, including transport for outside care, for emergencies including: (1) Medical emergencies; and (2) Mental health emergencies.
d. Cermak shall ensure that all inmates with emergency health care needs receive timely and appropriate care, with prompt referrals for outside care when medically necessary, and shall notify CCDOC when emergency transport is needed inside or outside the Facility compound, for emergencies including: (1) Medical emergencies; and (2) Mental health emergencies.
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e. CCDOC shall train all correctional officers to provide first responder assistance (including cardiopulmonary resuscitation (“CPR”) and addressing serious bleeding) in emergency situations. CCDOC shall provide all correctional officers with the necessary protective gear, including masks and gloves, to provide first line emergency response.
Compliance Status: This provision remains in Substantial Compliance.
Status Update: Received and reviewed.
Monitor’s Findings: Cermak has a good training program for their healthcare staff to recognize and respond to
healthcare emergencies. CDOC provides training to the correctional officers to recognize and respond to
healthcare emergencies. Patients who need emergency health care are promptly identified and transported to the
urgent care clinic and to the hospital if indicated. The Paramedics are now documenting directly in the electronic medical record. This is a new change since our last visit.
Nurses assess the patient and send them to the urgent care for further evaluation if needed. Nurses use a standard template that captures all relevant information. There is a warm handoff process between the floor nurse and the Urgent Care team.
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The Physicians in the Urgent Care clinic are performing complete evaluations. They provide timely and appropriate care for their patients. Patients who need to be sent to outside hospital are transported timely.
Hypoglycemic events are continuing to be monitored by the quality program and targeted training is being performed.
Critical lab results are reviewed and addressed by the providers in a timely manner. This process is being monitored by the physician leadership for compliance. Monitor’s Recommendations:
1. Perform chart audits for Urgent Care visits to identify opportunities for improvement 47. Record Keeping
a. Cermak 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 the Facility and are maintained consistent with local, federal, and state medical records requirements.
b. Cermak 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.
c. To ensure continuity of care, Cermak shall submit appropriate medical information to outside medical providers when inmates are sent out of the Facility for medical care. Cermak shall appropriately request 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. 21

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d. Cermak shall maintain unified medical and mental health records, including documentation of all clinical information regarding evaluation and treatment.
Compliance Status: This provision remains in substantial compliance for more than 18 months.
Status Update: All elements of record keeping remain in compliance for 18 months or longer.
Monitor’s Findings: There have been no lapses in compliance. Monitor’s Recommendations:
None. 48. Mortality Reviews
a. Cermak shall request an autopsy, and related medical data, for every inmate who dies while in the custody of CCDOC, including inmates who die following transfer to a hospital or emergency room.
b. Relevant CCDOC personnel shall participate in Cermak’s mortality review for each inmate death while in custody, including inmates who die following transfer to a hospital or emergency room, 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 seek to determine whether there was a systemic or specific problem that may have contributed to the incident. At a minimum, CCDOC’s contribution to mortality and morbidity reviews shall include:
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I. Critical review and analysis of the correctional circumstances surrounding the incident;
II. Critical review of the correctional procedures relevant to the incident; III. Synopsis of all relevant training received by involved correctional staff; IV. Possible precipitating correctional factors leading to the incident; and V. Recommendations, if any, for changes in correctional policy, training, physical
plant, and operational procedures. c. Cermak shall conduct a mortality review for each inmate death while in custody,
including inmates who die following transfer to a hospital or emergency room, and a morbidity review for all serious suicide attempts or other incidents in which an inmate was at high risk for death. Cermak shall engage relevant CCDOC personnel in mortality and morbidity reviews 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:
I. Critical review and analysis of the circumstances surrounding the incident; II. Critical review of the procedures relevant to the incident; III. Synopsis of all relevant training received by involved staff; IV. Pertinent medical and mental health services/reports involving the victim; V. Possible precipitating factors leading to the incident; and VI. Recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures.
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d. Cermak shall address any problems identified during mortality and morbidity reviews through timely training, policy revision, and any other appropriate measures.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Received and reviewed. Monitor’s Findings:
There have been six death-in-custody cases since our last visit in November 2017 including one suicide. The mortality review/ root cause analysis (RCA) for all deaths in custody cases were reviewed by the Monitoring Team. We found the RCAs to be comprehensive and multidisciplinary with succinct action plan items. The suicide occurred in a detainee with no past psychiatric history and no identifiable suicide risk despite several documented encounters with behavioral health staff. The remaining death in custody cases were not considered to be preventable. Monitor’s Recommendations:
Continue to place focused attention on prevention of suicide deaths. 49. Grievances
Cermak shall develop and implement policies and procedures for appropriate handling of grievances relating to health care, when such grievances are forwarded from CCDOC. Compliance Status:
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This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot checking. Spot check was conducted. Status Update:
None. Monitor’s Findings:
Spot check showed no lapses in compliance. Monitor’s Recommendations:
None. C. MEDICAL CARE 50. Health Assessments a. Cermak shall ensure that Qualified Medical Professionals attempt to elicit the amount,
frequency and time since the last dosage of medication from every inmate reporting that he or she is currently or recently on medication, including psychotropic medication. b. Cermak shall ensure that incoming inmates who present and are identified by medical personnel as having either a 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 or Qualified Mental Health Staff with appropriate, on-site supervision 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.
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c. Cermak shall ensure that all inmates at risk for, or demonstrating signs and symptoms of, drug and alcohol withdrawal are timely identified. Cermak shall provide appropriate treatment, housing, and medical supervision for inmates suffering from drug and alcohol withdrawal.
d. CCDOC shall maintain a policy 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.
e. Cermak shall ensure that the medical assessment performed within two working days of his or her booking at the Facility, or sooner if clinically indicated, for each inmate specified above (provision 45.f, “Intake Screening”) shall include a review of the inmate’s intake screening form, a medical history, a physical examination, a mental health history, and a current mental status examination. The physical examination shall be conducted by a Qualified Medical Professional. The medical assessment shall also include development or revision of the inmate’s problem list and treatment plan to address issues identified during the medical assessment. 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 medical assessment within the previous six months and whose receiving screening shows no change in the inmate’s health status need not receive a new medical assessment. For such inmates, Qualified Medical Staff shall review prior records and update tests and examinations as needed.
Compliance Status: 26

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This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot checking. Monitor’s Findings:
Spot checking showed that this area remains in substantial compliance. Monitor’s Recommendations: 3. Cermak leadership should continue periodic CQI studies assessing the appropriateness,
timeliness and quality of care. 4. The QI program should continue to monitor the documentation of timely receipt of
medications that are deemed critical. 51. Acute care 51a. Urgent Care
Cermak 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 care will include timely medical appointments and follow-up medical treatment. Compliance Status:
This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Reviewed Monitor’s Findings:
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This provision remains in substantial compliance. Monitor’s Recommendations:
None. 51b. Acute Care-Infirmary
a. Cermak shall maintain guidelines for the scope of care of acutely ill patients in its on-site designated infirmary units and for transfer of patients when appropriate to outside hospitals.
Compliance Status: This provision remains in Substantial Compliance
Status Update: Received and reviewed.
Monitor’s Findings: Cermak has a strong Infirmary program that manages higher acuity patients. Patients are appropriately referred to this program. Upon arrival to the unit, infirmary nurse performs a full nursing assessment of the patients and develops a nursing care plan. The provider evaluates the patient and assign an acuity level. Patients are followed up by the physician and the nurse based on their acuity level. The nurse sends the patient to the urgent care for any concerns during evenings and weekends. The facility is clean and well maintained. Monitor’s Recommendations:
Continue to monitor performance metrics 28

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52. Chronic Care a. Cermak shall maintain an appropriate, written chronic care disease management plan, which provides inmates with chronic diseases with timely and appropriate diagnosis, treatment, medication, monitoring and continuity of care consistent with the inmates’ expected length of stay. b. Cermak shall maintain appropriate written clinical practice guidelines for chronic diseases, such as HIV, hypertension, diabetes, asthma and elevated blood lipids. c. Cermak shall maintain an updated registry to track all inmates with serious and/or chronic illnesses and shall monitor this registry to ensure that these inmates receive necessary diagnoses and treatment. Cermak shall keep records of all care provided to inmates diagnosed with chronic illnesses in the inmates’ individual medical records. d. Cermak shall ensure that inmates with chronic conditions are routinely seen by a physician, physician assistant, or advanced practice nurse to evaluate the status of their health and the effectiveness of the medication administered for their chronic conditions. e. CCDOC shall house inmates with disabilities, or who need skilled nursing services or assistance with activities of daily living, in appropriate facilities, as determined by Cermak. CCDOC shall permit inmates with disabilities to retain appropriate aids to impairment, as determined by Cermak. f. Cermak shall ensure that inmates with disabilities or who need skilled nursing services or assistance with activities of daily living shall receive medically appropriate care. Cermak shall notify CCDOC of their specific needs for housing and aids to impairment. g. Cook County shall build out, remodel, or renovate clinical space as needed to provide appropriate facilities for inmates with disabilities in accordance with the timelines set out
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in provision 43.i. Prior to completion of the new clinical space, Cook County and DFM will work with Cermak to address the most serious concerns regarding facilities for inmates with disabilities, to the extent possible in the current Facility. Compliance Status: This provision remains in Substantial Compliance Status Update: Received and reviewed. Monitor’s Findings: The Monitoring Team reviewed the chronic care program and also the health records of randomly selected chronic disease patients. Cermak maintains an appropriate, written chronic care disease management plan. The plan is comprehensive and helps guide the clinical staff. Patients with chronic diseases are seen timely and appropriate diagnosis, treatment and follow-up care are provided. Cermak maintains appropriate written clinical practice guidelines for the major chronic diseases. The Power Notes and the order sets built in the electronic medical record enables the provider to easily follow the established clinical guidelines. Cermak maintains an updated chronic disease registry to track all patients with chronic medical conditions. This registry is used on a daily basis to track individual patients and group of patients with specific health conditions. Patients with chronic conditions are identified at Intake and referred to a provider immediately. The provider evaluates the patient and starts them on treatment. Patients are sent to the appropriate housing location to ensure safety and continuity of care.
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Appointments for follow-up care are scheduled by the scheduling team and tracked to ensure that the patients get seen. During the visit, the Providers address all aspects of care that includes compliance with medications, lab work, and referrals to specialists. Patients with disabilities, or who need skilled nursing services are housed in locations as recommended by the providers. CCDOC allows patients with disabilities to retain appropriate aids to impairment, as ordered by the providers. Patients with disabilities are housed in the appropriate housing units and are provided medically appropriate care. The facility is able to accommodate the needs of patients with disabilities. Our review of 5 records of HIV patients showed that patients were timely medically screened and referred for a secondary health assessment. HIV providers also timely saw patients following their arrival. At the initial appointment, clinicians performed a history and physical examination and ordered labs in accordance with current guidelines, with the exception that, as noted at the last visit QuantiFeron testing was performed in 3 of 5 patients. Providers assessed patients’ readiness to begin or restart antiretroviral therapy; and prophylaxis for opportunistic infections was initiated when clinically indicated. Medication administration Records (MAR’s) showed that patients received continuity of antiretroviral medications and prophylaxis for opportunistic infections. At follow-up visits, HIV providers reviewed pertinent lab test results and counseled patients. Overall, we found HIV care to be excellent. Monitor’s Recommendations:
1. Continue established audits and reports to track performance. 53. Treatment and Management of Communicable Diseases
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a. Cermak shall maintain adequate testing, monitoring and treatment programs for management of communicable diseases, including tuberculosis (“TB”), skin infections, and sexually transmitted infections (“STIs”).
b. CCDOC shall comply with infection control policies and procedures, as developed by Cermak, that address contact, blood borne, and airborne hazards, to prevent the spread of infections or communicable diseases, including TB, skin infections, and STIs, consistent with generally accepted correctional standards of care.
c. Cermak shall maintain 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, consistent with generally accepted correctional standards of care. Such policies should provide guidelines for identification, treatment and containment to prevent transmission of infectious diseases to staff or inmates.
d. Pursuant to Centers for Disease Control (“CDC”) Guidelines, Cermak shall continue to test all inmates for TB upon booking at the Facility and shall follow up on test results as medically indicated. Cermak shall follow current CDC guidelines for management of inmates with TB infection, including providing prophylactic medication when medically appropriate and consistent with the inmate’s expected length of stay. Inmates who exhibit signs or symptoms consistent with TB shall be isolated from other inmates, evaluated for contagious TB and housed in an appropriate, specialized respiratory isolation (“negative pressure”) room. Cermak shall notify CCDOC of inmates’ specific housing requirements and precautions for transportation for the purpose of infection control.
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e. Cermak shall ensure that the negative pressure and ventilation systems function properly. Following CDC guidelines, Cermak shall test daily for rooms in-use and monthly for rooms not currently in-use. Cermak shall document results of such testing.
f. Cermak shall notify DFM, in a timely manner, of routine and emergency maintenance needs, including plumbing, lighting and ventilation problems.
g. Cermak 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.
h. Cermak shall adequately maintain statistical information regarding communicable disease screening programs and other relevant statistical data necessary to adequately identify, treat, and control infectious diseases.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Status update received and reviewed. Monitor’s Findings:
Spot checking showed no lapses in compliance. Monitor’s Recommendations:
None. 54. Access to Health Care
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a. CCDOC will work with Cermak to facilitate timely and adequate accessibility of appropriate health care for inmates, as provided by Cermak. b. Cermak shall ensure the timely and adequate availability of appropriate health care for inmates. c. Cermak 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. written medical and mental health care slips available in English, Spanish and other languages, as needed; ii. opportunity for illiterate inmates and inmates who have physical or cognitive disabilities to access medical and mental health care; and iii. opportunity for all inmates, irrespective of primary language, to access medical and mental health care. d. Cermak shall ensure that the sick call process includes confidential collection, logging and tracking of sick call requests seven days a week. Cermak shall ensure timely responses to sick call requests 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. Cermak shall document the reason for and disposition of the medical or mental health care request in the inmate’s medical record.
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e. Cermak shall develop and implement an effective system for screening medical requests within 24 hours of submission. Cermak shall ensure that sick call requests are appropriately prioritized based upon the seriousness of the medical issue. f. Cermak shall ensure that evaluation and treatment of inmates in response to a sick call request occurs in a clinical setting. g. Cermak 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. Compliance Status: This provision remains in substantial compliance. Status Update: The Monitoring Team was provided and reviewed access to care data in preparation for the November 2017 Monitoring Tour. Monitor’s Findings: The Monitoring Team evaluated inmate access to care by reviewing health service request tracking systems, health service request (HSR) forms and health records, In addition, Cermak health care leadership presented results of a new access to care database that tracked each health services request.
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At the last monitoring visit in November 2017, all elements of Access to Care remained in substantial compliance. Substantial compliance was sustained for all access to care provisions at this monitoring visit. The monitoring team reviewed a sample of approximately 110 health services requests (HSR) from all divisions submitted by inmates in March and April 2018, including dental requests. We found that staff timely collected and signed HSRs upon receipt. Nurses timely triaged HSR’s and legibly dated forms. Nurses consistently documented appropriate triage dispositions on the form. Nurses timely saw patients for both urgent and routine complaints. Nurses referred patients to providers as clinically indicated and appointments generally timely took place. Nurses documented assessments into Cerner using nursing protocols using a Power Note that does not facilitate documentation of concise and pertinent notes and nurses do not acknowledge previous medical provider care pertinent to the patient’s complaint that support nursing assessments. This contributes to variability in quality of nursing assessments. We also found instances in which nursing assessments are not consistent with Cermak Nursing Guidelines and/or good clinical judgement. Compliance with the Agreed Order is further described below. a. Remains in substantial compliance. b. Remains in substantial compliance. c. Remained in substantial compliance. d. Remains in substantial compliance. e. Remains in substantial compliance. f. Remains in substantial compliance.
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g. Remains in substantial compliance. Recommendations:
1. Health care leadership should continue to provide physical assessment and nurse protocol training to nursing staff to increase their baseline knowledge and skills regarding the most common patient conditions.
2. Health care leadership should work to revise the Cerner Power Note to enable nurses to document more pertinent and concise notes, or use another type of form to document nursing assessments.
3. When patients submit HSRs, nurses should review the medical record to determine whether another nurse or medical provider has recently treated the patient for the same condition, and document this information in support of assessments and treatment plans.
4. Nurses should continue to assess all patients with dental pain and refer to dental in accordance with the urgency of the complaint.
5. Health care leadership and nurse managers should continue to perform CQI studies regarding nursing performance to provide feedback to nurses.
55. Follow-Up Care a. Cermak shall provide adequate care and maintain appropriate records for inmates who return to the Facility following hospitalization or outside emergency room visits. b. Cermak shall ensure that inmates who receive specialty, emergency room, or hospital care are evaluated upon their return to the Facility 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
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documentation are recorded in the inmate’s medical record, and appropriate follow-up is provided. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot checking. Status Update: Received and reviewed. Monitor’s Findings: The Monitoring Team reviewed the process and the health records of patients returning from hospitalization and emergency room visits. Cermak shares the same electronic medical record system with the hospital. The clinical staff have access to the emergency department, inpatient and specialty clinic documents. As a standard practice, the providers review the hospital records and use it to develop a treatment plan to ensure continuity of care. Patients returning from the emergency room or hospital care are evaluated by a provider in the Urgent Care clinic. The provider reviews the hospital records and orders appropriate housing, medications and follow-up plan for the patient. Monitor’s Recommendations:
1. Continue with the established audits and reports. 56. Medication Administration
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a. Cermak shall ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted correctional standards of care.
b. Cermak shall develop policies and procedures to ensure the accurate administration of medication and maintenance of medication records. Cermak 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. Cermak shall ensure that medicine administration is hygienic, appropriate for the needs of inmates and is recorded concurrently with distribution.
d. Cermak shall ensure that medication administration is performed by Qualified Nursing Staff.
e. When Cermak prescribes medication to address an inmate’s serious mental health needs, HIV or AIDS, or thromboembolic disease, Cermak shall alert CCDOC that the inmate in question is on a flagged medication. If the prescription is terminated during an inmate’s stay at the Facility, Cermak will notify CCDOC.
f. When CCDOC receives notice that an inmate is on a flagged medication, CCDOC shall include notation of a medication flag in the inmate’s profile on the Facility’s Jail Management System.
g. When an inmate with a medication flag is processed for discharge at the Facility, CCDOC shall escort the inmate to designated Cermak staff in the intake screening area of the Facility for discharge medication instructions.
h. When CCDOC escorts an inmate with a medication flag to Cermak staff during discharge processing, Cermak staff shall provide the inmate with printed instructions regarding prescription medication and community resources.
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i. Each morning, CCDOC shall provide Cermak with a list of all inmates with medication flags who were discharged the previous day.
j. Within 24 hours of discharge of an inmate with a medication flag, Cermak shall call in an appropriate prescription to the designated pharmacy on the Stroger Hospital campus to serve as a bridge until inmates can arrange for continuity of care in the community.
k. CCDOC shall ensure that information about pending transfers of inmates is communicated to Cermak as soon as it is available.
l. When CCDOC has advance notice and alerts Cermak of the pending transfer to another correctional facility of inmates with serious medical or mental health needs from detention, Cermak shall supply sufficient medication for the period of transit. In such cases, Cermak shall prepare and send with transferring inmates a transfer summary detailing major health problems and listing current medications and dosages, as well as medication history while at the Facility.
m. CCDOC shall ensure that the transfer summary and any other medical records provided by Cermak will accompany inmates, or will be made available electronically or transmitted by facsimile, when they are transferred from the Facility to another institution.
Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as
such will no longer be formally monitored except for spot check monitoring as indicated. Status Update:
Status update reviewed. Monitor’s Findings:
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Spot checking showed no lapses in compliance. Monitor’s Recommendations:
None 57. Specialty Care Cermak shall ensure that inmates whose serious medical or mental health needs extend beyond the services available at the Facility shall receive timely and appropriate referral for specialty care to appropriate medical or mental health care professionals qualified to meet their needs.
a. Upon reasonable notification by Cermak, CCDOC will transport inmates who have been referred for outside specialty care to their appointments.
b. Cermak 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. Cermak shall provide reasonable notice to CCDOC of such appointments so that CCDOC can arrange transportation. Inmates waiting outside care shall be seen by Qualified Medical Staff as medically necessary, at clinically appropriate intervals, to evaluate the current urgency of the problem and respond as medically appropriate. If an inmate refuses treatment following transport for a scheduled appointment, Cermak shall have the inmate document his refusal in writing and include such documentation in the inmate’s medical record.
c. Cermak 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.
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d. Cermak shall ensure that pregnant inmates are provided adequate pre-natal care. Cermak shall develop and implement appropriate written policies and protocols for the treatment of pregnant inmates, including appropriate screening, treatment and management of highrisk pregnancies.
Compliance Status: This provision remains in Substantial Compliance
Status Update: Received and reviewed.
Monitor’s Findings: The Monitoring Team reviewed health records of patients returning from offsite specialty
clinics and procedures. Patients who require specialty clinic visits receive timely and appropriate referrals. The
referrals are tracked by the referring provider and the coordinator. Urgent referrals are identified and processed more quickly.
The appointment list is reviewed by the physician leadership and given to the CCDOC team for transportation. Patients are taken to their appointment appropriately. The clinical team and the CCDOC team actively communicate and collaborate on this process. Patients waiting for outside care are continued to be monitored by the Medical Staff as medically necessary.
When patients refuse an offsite appointment, they are educated on the risk of refusal and the refusal is documented in the medical record.
Cermak maintains an active log of all offsite referrals. The status and the details of referrals are tracked in the log by the referral coordinator.
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Cermak provides adequate pre-natal care for the pregnant patients. Cermak has a comprehensive program to appropriately screen and manage high-risk pregnancies. Monitor’s Recommendations:
1. Continue tracking referrals and monitor turnaround time for each clinic 58. Dental Care
Cermak shall ensure that inmates receive adequate dental care, and follow up, in accordance with generally accepted correctional standards of care. Such care should be provided in a timely manner, taking into consideration the acuity of the problem and the inmate’s anticipated length of stay. Dental care shall not be limited to extractions.
a. Cermak shall ensure that adequate dentist staffing and hours shall be provided to avoid unreasonable delays in dental care.
Compliance Status: This provision remains in substantial compliance.
Status Update: Received and reviewed on site.
Monitors’ findings: While Cermak census continues to decrease, the total number of dental encounters has
remained stable over the past 18 months. Cermak dental now schedules 100% of all dental appointments.
Cermak now has two vacant dentist positions, the Chief Dentist and a front line dentist staff. This position is currently being recruited.
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Oral surgery needs of the Cermak detainees are continued to be met via Stroger OMFS services.
Again, the Monitoring Team received from Cermak dental services a comprehensive selfassessment and process improvement plan that included action plan items and audit results for the past 6 months as well as encounter and quality improvement data for the past couple of years. Included in this document were monthly encounter numbers as well as a breakdown of extractions vs. restorative procedures. Cermak continues to perform a very high percentage of restorations vs. extractions. This is a best in class performance and has a significant positive impact on the oral health of the inmates at Cook County Jail and the overall oral health of the Cook County residents. The issue of inconsistent nursing evaluation of dental health services request forms has been eliminated. We found near 100% nurse encounters for every dental health service request form. This is to be commended. Similar to our last visits, the Monitoring Team audited several dental encounters from different Cermak Divisions with regard to:
 Date of actual HSR  Date the HSR was received by dental clinic  Date of dental clinic appointment
 Reason for visit (symptomatic vs. asymptomatic)
 Documentation regarding face to face nursing encounters when such encounter was indicated
The timeliness for the dental services for annual screening, routine and priority has remained acceptable (within 90 days, 30 days and 14 days respectively). The wait time for urgent dental complaints continues to surpass the goal of 3 business days and is currently around 7days. It is important to note, however, that all true urgent dental conditions were in fact evaluated by dental
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services within 48 hours per our audit of dental health services request forms and the actual dental visits (majority were evaluated by the dentist within 24 hours). The Monitoring Team discovered that any and all dental health service request forms that mentions “pain” or “swelling” is automatically labeled as “urgent” regardless of the face to face nursing encounter that occurs prior to the dental appointment. This approach was at one time in the past necessary to avoid potential missed opportunities in the event that face to face nursing encounters would not occur. This is no longer the case. Our audit confirmed the overall self-assessment report with regard to nurse sick call encounters that was presented to the Monitoring Team by Cermak dental services indicating consistent and near 100% reliable nurse encounter for every dental health service request. Monitor’s Recommendations:
1. Consider allowing nursing staff to suggest the acuity of dental health service request forms based on their face to face evaluation of detainees in order to decrease the number of false “urgent” appointments. This would in turn allow the dental service to focus more on truly urgent dental complaints. Further training of nursing staff on screening dental exams may be necessary.
2. Continue to recruit the vacant dentist position. The Monitoring Team hopes that the replacement of the currently vacant dentist positions will further enhance the dental services program at Cermak and reduce the overall wait times.
68. Suicide Prevention Training a. Cermak shall ensure that the Facility’s suicide prevention curriculum for health care staff members, jointly established with CCDOC, addresses the following topics:
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i. the suicide prevention policy as revised consistent with this Agreed Order; 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 (Serious suicide
attempts are typically considered to be those that either were potentially lifethreatening or that required medical attention); ix. mock demonstrations regarding the proper response to a suicide attempt; and x. The proper use of emergency equipment, including suicide cut-down tools. b. Within 24 months of the effective date of this Agreed Order, CCDOC shall train all CCDOC staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. 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 in accordance with generally accepted professional standards. c. Within 12 months of the effective date of this Agreed Order, Cermak shall train all Cermak staff members who work with inmates on the Facility’s suicide prevention program. Implementation of such training shall begin as soon as possible following the effective date of this Agreed Order. Staff shall demonstrate competency in the verbal
46

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 47 of 49 PageID #:5856
and behavioral cues that indicate potential suicide, and how to respond appropriately. Initial and at least annual training shall be provided in accordance with generally accepted professional standards. Compliance Status: This provision has remained in substantial compliance for 18 months or longer and as such will no longer be formally monitored except for spot check monitoring as indicated Monitor’s Findings: There was one suicide death since our last monitoring visit. This event, however, occurred in a general population inmate with no warning signs. Monitor’s Recommendations: Continue the annual training of Cermak and CCDOC staff with regard to suicide prevention. 86. Quality Management and Performance Measurement a. Defendants shall each develop and implement written quality management policies and procedures, in accordance with generally accepted correctional standards, to regularly assess, identify, and take all reasonable measures to assure compliance with each of the provisions of this Agreed Order applicable to that Defendant. b. Defendants shall each 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, for each of the provisions of this Agreed Order applicable to that Defendant. c. CCDOC shall participate with Cermak and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a
47

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 48 of 49 PageID #:5857
joint quality improvement program. CCDOC shall contribute the time and effort of CCDOC staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. d. Cermak shall participate with CCDOC and DFM in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. Cermak will work with CCDOC and DFM to identify those CCDOC and DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. 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. e. DFM shall participate with CCDOC and Cermak in a jointly established Health Care Quality Improvement Committee, to be charged with developing and implementing a joint quality improvement program. DFM shall contribute the time and effort of DFM staff members who, by virtue of their authority, current responsibilities, and/or past experience, can provide this committee with needed correctional representation. Compliance Status: This provision remains in Substantial Compliance. Status Update: Received and reviewed. Monitor’s Findings:
48

Case: 1:10-cv-02946 Document #: 373 Filed: 06/12/18 Page 49 of 49 PageID #:5858
Cermak maintains a written quality management policy and procedures in accordance with generally accepted correctional standards. The quality program is comprehensive and tracks compliance with the requirements and established measures. Cermak quality program identifies specific improvement activities and tracks their progress. The performance of each program and the status of the improvement activities are discussed during the monthly Quality meetings. Cermak is a strong data driven program. They use several performance dashboards and real-time data to measure performance and track progress. CCDOC and Cermak collaborate well and have joint meetings to discuss quality improvement initiatives. Cermak has a culture of learning and continuous improvement. Monitor’s Recommendations:
1. Share your learnings and best practices with other organizations
49

 
 Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 1 of 25
ASHMAN,RELATED,TERMED
United States District Court Northern District of Illinois − CM/ECF LIVE, Ver 6.3.2 (Chicago)
CIVIL DOCKET FOR CASE #: 1:10−cv−02946

United States of America v. Cook County, Illinois et al Panel: Honorable Virginia M. Kendall
Honorable Richard A. Posner Honorable Sharon Johnson Coleman Cause: 42:1983 Civil Rights Act
Plaintiff

Date Filed: 05/13/2010 Date Terminated: 06/26/2018 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

United States of America

represented by Cathleen Siobhan Trainor United States Department of Justice 601 D. Street, NW Washington, DC 20004 202 616 9009 Email: cathleen.trainor@usdoj.gov ATTORNEY TO BE NOTICED

Corey M Sanders United States Department Of Justice 601 D. Street, Nw Washington, DC 20004 (202) 305−3229 Email: corey.sanders@usdoj.gov ATTORNEY TO BE NOTICED

Kerry Krentler Dean United States Department Of Justice 950 Pennsylvania Ave NW PHB 5026 Washington, DC 20530 (202) 514−1841 Email: kerry.k.dean@usdoj.gov ATTORNEY TO BE NOTICED

Kyle E. Smiddie U.S. Department of Justice 601 D. Street, N.W. Washington, DC 20004 202 307 6581 Email: kyle.smiddie@usdoj.gov ATTORNEY TO BE NOTICED

Michelle A Jones Department of Justice 950 Pennsylvania Ave. NW Phb−5421e Washington, DC 20011 202 305 3642 Email: michelle.jones2@usdoj.gov ATTORNEY TO BE NOTICED

Patrick Walter Johnson United States Attorney's Office (NDIL) 219 South Dearborn Street Suite 500 Chicago, IL 60604 (312) 353−5300 Email: patrick.johnson2@usdoj.gov ATTORNEY TO BE NOTICED

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 2 of 25

V. Petitioner Barbara Lyons V. Defendant Cook County, Illinois
Defendant Thomas Dart Cook County Sheriff (in his official

represented by Adele D. Nicholas Law Office of Adele D. Nicholas 5707 W. Goodman Chicago, IL 60630 847 361 3869 Email: adele@civilrightschicago.com ATTORNEY TO BE NOTICED
represented by Patrick T. Driscoll , Jr. c/o Neville and Mahoney 221 N. La Salle St. Suite 2100 Chicago, IL 60601 (312) 236−2100 Email: ptdriscoll@aol.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Anthony E. Zecchin Hale Law LLC 53 West Jackson Blvd. Suite 330 Chicago, IL 60604 (312) 870−6933 Email: azecchin@ahalelaw.com ATTORNEY TO BE NOTICED
Colleen B. Cavanaugh O'Rourke, Hogan, Fowler & Dwyer, LLC 10 South LaSalle Street, Suite 3700 Chicago, IL 60603 (312) 739−3500 Email: ccavanaugh@ohfdlaw.com ATTORNEY TO BE NOTICED
Donald J. Pechous The Khowaja Law Firm LLC 8 South Michigan Ave., 26th Floor Chicago, IL 60603 (312) 356−3200 Email: dpechous@khowajalaw.com ATTORNEY TO BE NOTICED
Paul Anthony Castiglione Cook County State's Attorney's Office (69W) 69 W. Washington Suite 3110 Chicago, IL 60602 (312) 603−1840 Email: pcastig@cookcountygov.com ATTORNEY TO BE NOTICED
represented by Daniel Francis Gallagher Vrdolyak Law Group, LLC

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 3 of 25

capacity) TERMINATED: 06/09/2017
Defendant Todd H Stroger Cook County Board President (in his official capacity)
Defendant Cook County Board of Commissioners (in their official capacity)

100 North Riverside Suite 2400 Chicago, IL 60606 (312) 482−8200 Email: dangallagher@vrdolyak.com TERMINATED: 04/04/2012 LEAD ATTORNEY
Darren K Angell Peterson, Johnson & Murray Chicago LLC 200 West Adams Street Suite 2125 Chicago, IL 60606 (312) 782−7150 Email: dangell@pjmchicago.com LEAD ATTORNEY ATTORNEY TO BE NOTICED
Daniel P Duffy Peterson, Johnson & Murray, SC 120 North LaSalle Street Suite 2850 Chicago, IL 60602 (312)782−7150 Email: dduffy@pjmlaw.com TERMINATED: 01/05/2018
Dominick L Lanzito Peterson Johnson & Murray − Chicago LLC 200 West Adams Street Suite 2125 Chicago, IL 60606 312 724−8024 Email: dlanzito@pjmchicago.com ATTORNEY TO BE NOTICED
Paul A O'Grady Peterson Johnson and Murray Chicago LLC 200 West Adams Street Suite 2125 Chicago, IL 60606 312 782−7150 Email: pogrady@pjmchicago.com ATTORNEY TO BE NOTICED
represented by Patrick T. Driscoll , Jr. (See above for address) LEAD ATTORNEY ATTORNEY TO BE NOTICED
Colleen B. Cavanaugh (See above for address) ATTORNEY TO BE NOTICED
Donald J. Pechous (See above for address) ATTORNEY TO BE NOTICED
represented by Patrick T. Driscoll , Jr. (See above for address)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 4 of 25

Defendant
Toni Preckwinkle
Amicus
Mr. Mark W. Solock Law Office of the Cook County Public Defender 69 W. Washington Suite 1600 Chicago, IL 60602 312−603−0640

LEAD ATTORNEY ATTORNEY TO BE NOTICED
Anthony E. Zecchin (See above for address) ATTORNEY TO BE NOTICED
Colleen B. Cavanaugh (See above for address) ATTORNEY TO BE NOTICED
Donald J. Pechous (See above for address) ATTORNEY TO BE NOTICED
Paul Anthony Castiglione (See above for address) ATTORNEY TO BE NOTICED

Date Filed 05/13/2010 05/13/2010 05/13/2010 05/13/2010 05/13/2010
05/13/2010
05/13/2010 05/13/2010 05/14/2010
05/19/2010

# Docket Text
1 COMPLAINT filed by United States of America; (Attachments: # 1 Exhibit A, # 2 Exhibit B)(Johnson, Patrick) Modified on 5/13/2010 (kj, ). (Entered: 05/13/2010)
2 CIVIL Cover Sheet (Johnson, Patrick) Modified on 5/13/2010 (kj, ). (Entered: 05/13/2010)
CASE ASSIGNED to the Honorable Matthew F. Kennelly. Designated as Magistrate Judge the Honorable Nan R. Nolan. (nsf, ) (Entered: 05/13/2010)
3 MOTION by Plaintiff United States of America for order entering agreed order (Attachments: # 1 Exhibit)(Johnson, Patrick) (Entered: 05/13/2010)
4 NOTICE of Motion by Patrick Walter Johnson for presentment of motion for order 3 before Honorable Matthew F. Kennelly on 5/27/2010 at 09:30 AM. (Johnson, Patrick) (Entered: 05/13/2010)
5 ATTORNEY Appearance for Defendants Cook County Board of Commissioners, Cook County, Illinois, Todd H. Stroger, Cook County Board President by Donald J. Pechous (Pechous, Donald) (Entered: 05/13/2010)
6 ATTORNEY Appearance for Defendant Thomas Dart, Cook County Sheriff by Daniel Francis Gallagher (Gallagher, Daniel) (Entered: 05/13/2010)
7 ATTORNEY Appearance for Defendant Thomas Dart, Cook County Sheriff by Paul A OGrady (OGrady, Paul) (Entered: 05/13/2010)
8 ATTORNEY Appearance for Defendants Cook County Board of Commissioners, Cook County, Illinois, Todd H. Stroger, Cook County Board President by Patrick T. Driscoll, Jr (Driscoll, Patrick) (Entered: 05/14/2010)
9 EXECUTIVE COMMITTEE ORDER: Case reassigned to the Honorable Virginia M. Kendall for all further proceedings. (See order for detail.) Signed by Executive

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 5 of 25

05/26/2010 05/26/2010 05/26/2010 05/26/2010 05/27/2010 05/27/2010 05/27/2010 06/03/2010 07/02/2010 07/02/2010 07/07/2010
07/07/2010
07/08/2010
08/17/2010 08/26/2010 08/26/2010 08/31/2010

Committee on 5/19/2010.(hp, ) (Entered: 05/21/2010)
10 ATTORNEY Appearance for Plaintiff United States of America by Kerry Krentler Dean (Dean, Kerry) (Entered: 05/26/2010)
11 MINUTE entry before Honorable Virginia M. Kendall:MOTION by Plaintiff United States of America for order entering agreed order 3 is stricken. Mailed notice (tsa, ) (Entered: 05/26/2010)
12 MINUTE entry before Honorable Virginia M. Kendall: Enter Agreed Order. Mailed (vmj, ) (Entered: 05/27/2010)
13 AGREED ORDER Signed by the Honorable Virginia M. Kendall on 5/26/2010.(vmj, ) (Entered: 05/27/2010)
14 MOTION by Defendant Thomas Dart for Entry of a Prisoner Release Order (Attachments: # 1 Exhibit A, # 2 Exhibit B)(Gallagher, Daniel) (Entered: 05/27/2010)
15 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion for miscellaneous relief 14 before Honorable Virginia M. Kendall on 6/3/2010 at 09:00 AM. (Gallagher, Daniel) (Entered: 05/27/2010)
16 ATTORNEY Appearance for Plaintiff United States of America by Corey M Sanders (Sanders, Corey) (Entered: 05/27/2010)
17 MINUTE entry before Honorable Virginia M. Kendall: Motion hearing held. Defendant Dart's motion for entry of a prisoner release order 14 is granted in part as outlined in open court.Advised in open court (jms, ) (Entered: 06/03/2010)
18 MOTION by Defendant Thomas Dart to Modify the Court's Order of July 17, 2009 and Agreed Order entered on May 26, 2010 (Attachments: # 1 Exhibit A, # 2 Exhibit B)(OGrady, Paul) (Entered: 07/02/2010)
19 NOTICE of Motion by Paul A OGrady for presentment of motion for miscellaneous relief 18 before Honorable Virginia M. Kendall on 7/8/2010 at 09:00 AM. (OGrady, Paul) (Entered: 07/02/2010)
20 MINUTE entry before Honorable Virginia M. Kendall: Hearing on Defendant Dart's motion to Modify the Court's Order of July 17, 2009 and Agreed Order entered on May 26, 2010 is stricken for failure to comply with Local Rule 5.2(f) and Judge Kendall's standing procedures.Mailed notice (jms, ) (Entered: 07/07/2010)
21 MINUTE entry before Honorable Virginia M. Kendall:The minute entry of 7/7/2010 is vacated. Hearing on defendant Dart's motion to modify this court's order of 7/17/2009 and agreed order entered on 5/26/2010 18 is set for 7/8/2010 at 09:00 AM.Mailed notice (jms, ) (Entered: 07/07/2010)
22 MINUTE entry before Honorable Virginia M. Kendall: Motion hearing held. MOTION by Defendant Thomas Dart to Modify the Court's Order of July 17, 2009 and Agreed Order entered on May 26, 2010 18 is granted to allow the Sheriff of Cook County to reclassify 59 Correctional officers into civilian position vacancies.Advised in open court (jms, ) (Entered: 07/08/2010)
23 WRITTEN Opinion Signed by the Honorable Virginia M. Kendall on 8/17/2010.(tsa, ) (Entered: 08/17/2010)
24 MOTION by Defendant Thomas Dart to Set a Pretrial Conference Instanter Pursuant to F.R.C.P. 16 (Gallagher, Daniel) (Entered: 08/26/2010)
25 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion for miscellaneous relief 24 before Honorable Virginia M. Kendall on 9/1/2010 at 09:00 AM. (Gallagher, Daniel) (Entered: 08/26/2010)
26 MINUTE entry before Honorable Virginia M. Kendall:MOTION by Defendant Thomas Dart to Set a Pretrial Conference Instanter Pursuant to F.R.C.P. 16 24 is granted. Status hearing set for 9/10/2010 at 10:00 AM. Parties need not appear in court on 9/1/2010.Mailed notice (tsa, ) (Entered: 08/31/2010)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 6 of 25

09/09/2010 09/10/2010 09/24/2010 09/24/2010 09/24/2010 09/24/2010 09/24/2010
09/24/2010 09/24/2010 09/24/2010 09/24/2010 09/24/2010 09/28/2010 09/28/2010 11/18/2010 11/18/2010 11/19/2010 11/24/2010
12/10/2010 12/10/2010

27 ATTORNEY Appearance for Defendants Cook County Board of Commissioners, Cook County, Illinois, Todd H Stroger by Colleen Bernadette Cavanaugh (Cavanaugh, Colleen) (Entered: 09/09/2010)
28 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 9/10/2010.Advised in open court notice (tsa, ) (Entered: 09/13/2010)
29 Monitor Susan W. McCampbell's First Compliance Report by Thomas Dart (Gallagher, Daniel) (Entered: 09/24/2010)
30 NOTICE by Thomas Dart re other 29 − Monitor Susan W. McCampbell's First Compliance Report (Gallagher, Daniel) (Entered: 09/24/2010)
31 Monitor Harry Grenawitzke's First Compliance Report by Thomas Dart (Gallagher, Daniel) (Entered: 09/24/2010)
32 NOTICE by Thomas Dart re other 31 − Monitor Harry Grenawitzke's First Compliance Report (Gallagher, Daniel) (Entered: 09/24/2010)
33 Monitor Jeffrey L. Metzner, M.D.'s First Compliance Report by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix VI, # 7 Appendix VII, # 8 Appendix VIII, # 9 Appendix IX, # 10 Appendix X)(Gallagher, Daniel) (Entered: 09/24/2010)
34 NOTICE by Thomas Dart re other, 33 − Monitor Jeffrey L. Metzner, M.D.'s First Compliance Report (Gallagher, Daniel) (Entered: 09/24/2010)
35 − Monitor Ronald Shansky, M.D.'s First Compliance Report by Thomas Dart (Attachments: # 1 Exhibit A)(Gallagher, Daniel) (Entered: 09/24/2010)
36 NOTICE by Thomas Dart re other 35 − Monitor Ronald Shansky, M.D.'s First Compliance Report (Gallagher, Daniel) (Entered: 09/24/2010)
37 MEMORANDUM Memorandum Supporting Motion to Extend Prisoner Release Order (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C)(Gallagher, Daniel) (Entered: 09/24/2010)
38 NOTICE by Thomas Dart re memorandum in support of motion 37 (Gallagher, Daniel) (Entered: 09/24/2010)
39 STATEMENT in support of Sheriff's Motion to Extend Prisoner Release Order by Cook County Board of Commissioners, Cook County, Illinois, Todd H Stroger (Pechous, Donald) Modified on 10/6/2010 (vmj, ). (Entered: 09/28/2010)
40 NOTICE by Cook County Board of Commissioners, Cook County, Illinois, Todd H Stroger re statement 39 (Pechous, Donald) (Entered: 09/28/2010)
41 MOTION by Defendant Thomas Dart for extension of time − Defendant Thomas J. Dart, Sheriff of Cook County's Agreed Motion for Extension of Time to File Response to Monitors' Report (Gallagher, Daniel) (Entered: 11/18/2010)
42 NOTICE of Motion by Daniel Francis Gallagher for presentment of extension of time 41 before Honorable Virginia M. Kendall on 11/24/2010 at 09:00 AM. (Gallagher, Daniel) (Entered: 11/18/2010)
43 MINUTE entry before Honorable Virginia M. Kendall:Defendant Dart's motion for extension of time 41 is entered and continued to 11/29/2010 at 09:00 AM.Mailed notice (tsa, ) (Entered: 11/19/2010)
44 MINUTE entry before Honorable Virginia M. Kendall:Agreed MOTION by Defendant Thomas Dart for extension of time File Response to Monitors' Report 41 is granted to 12/10/2010. Parties need not appear in court on 11/29/2010. Mailed notice (tsa, ) (Entered: 11/24/2010)
45 STATUS REPORT AND RESPONSE by Defendant Cook County, Illinois to Monitors' Reports (Pechous, Donald) (Text Modified by Clerk's Office on 12/13/2010.) (hp, ). (Entered: 12/10/2010)
46 NOTICE by Cook County, Illinois re Response 45 (Pechous, Donald) (Entered: 12/10/2010)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 7 of 25

12/10/2010 12/10/2010 12/13/2010 12/13/2010 12/15/2010
12/15/2010 12/17/2010 12/21/2010 12/21/2010 12/21/2010 12/21/2010 12/23/2010 01/05/2011 01/07/2011 01/11/2011
01/11/2011 02/10/2011

47 RESPONSE by Defendant Thomas Dart to the Monitors' Reports (Attachments: # 1 Exhibit List)(Gallagher, Daniel) (Entered: 12/10/2010)
48 NOTICE by Thomas Dart re Response 47 to the Monitors' Reports (Gallagher, Daniel) (Entered: 12/10/2010)
49 MOTION by Defendant Thomas Dart to seal Exhibit M to the Response to the Monitors' Reports (Gallagher, Daniel) (Entered: 12/13/2010)
50 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion to seal 49 before Honorable Virginia M. Kendall on 12/20/2010 at 09:00 AM. (Gallagher, Daniel) (Entered: 12/13/2010)
51 MINUTE entry before Honorable Virginia M. Kendall:The PLRA panel: United States Court of Appeals Judge, Richard Posner, United States District Court Judge, Virginia Kendall, and United States District Court Judge, Sharon Johnson Coleman, enters the following order: The panel will conduct a hearing in the Seventh Circuit courtroom (Dirksen Building, 27th Floor) at 2 p.m. on Friday, January 7, to consider the motion for a release order. The panel will hear argument but, if necessary, brief testimony as well. The tentative time allotment is thirty minutes per side. Mailed notice (tsa, ) (Entered: 12/15/2010)
52 MINUTE entry before Honorable Virginia M. Kendall:Enter attached order.Mailed notice (tsa, ) (Entered: 12/15/2010)
53 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendant Thomas Dart to seal Exhibit M to the Response to the Monitors' Reports 49 is granted.Mailed notice (tsa, ) (Entered: 12/17/2010)
54 Monitor Jeffrey L. Metzner, M.D.'s Second Report Dated December 21, 2010 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III)(Gallagher, Daniel) (Entered: 12/21/2010)
55 NOTICE by Thomas Dart re other 54 − Monitor Jeffrey L. Metzner, M.D.'s Second Report Dated December 21, 2010 (Gallagher, Daniel) (Entered: 12/21/2010)
56 MOTION by Plaintiff United States of America to continue Prisoner Release Order Hearing (Dean, Kerry) (Entered: 12/21/2010)
57 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to continue 56 before Honorable Virginia M. Kendall on 1/6/2010 at 09:00 AM. (Dean, Kerry) (Entered: 12/21/2010)
58 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America to continue Prisoner Release Order Hearing 56 is denied.Mailed notice (tsa, ) (Entered: 12/23/2010)
59 RESPONSE to Panel's Questions by United States of America (Attachments: # 1 Exhibit A − USDOJ Findings Letter, # 2 Exhibit B − CCDOC Logs)(Dean, Kerry) Modified on 1/6/2011 (vmj, ). (Entered: 01/05/2011)
60 MINUTE entry before Honorable Virginia M. Kendall:In court hearing held on 1/7/2011 before the Special Three Judge Panel.Advised in open court notice (tsa, ) (Entered: 01/11/2011)
61 MINUTE entry before Honorable Virginia M. Kendall:Enter OPINION OF THREE−JUDGE DISTRICT COURT: The motion for entry of the proposed release order is denied, but without prejudice, and the parties are directed to submit a revised motion consistent with the discussion in this opinion, plus evidence to support an estimate of the number of prisoners expected to be released if the revised order is approved. The revised order and any supporting materials are due 30 days from the date of this order. Mailed notice (tsa, ) (Entered: 01/11/2011)
62 Opinion Signed on 1/11/2011.(tsa, ) (Entered: 01/11/2011)
63 Support for Prisoner Release Order STATEMENT by United States of America (Dean, Kerry) (Entered: 02/10/2011)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 8 of 25

02/18/2011 03/01/2011 03/01/2011 03/14/2011
03/14/2011 03/29/2011 03/29/2011 04/07/2011 04/28/2011 04/28/2011 04/29/2011 04/29/2011 04/29/2011 04/29/2011 04/29/2011 05/02/2011
05/02/2011 06/02/2011 06/02/2011

64 MINUTE entry before Honorable Virginia M. Kendall:The panel will conduct a status hearing in this case on Tuesday, March 1,2011, at 10:00 a.m. in Judge Kendalls Courtroom, Room 2319.Mailed notice (tsa, ) (Entered: 02/18/2011)
65 ATTORNEY Appearance for Plaintiff United States of America by Michelle A Jones (Jones, Michelle) (Entered: 03/01/2011)
66 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 3/1/2011.Advised in open court notice (tsa, ) (Entered: 03/02/2011)
67 MINUTE entry before Honorable Virginia M. Kendall:Enter ORDER OF THREE−JUDGE DISTRICT COURT: The revised proposed order complies with the directives in this Courts opinion and is satisfactory with the exception of one provision. If the jail wants to release more inmates it should be required to obtain the Courts permission.Mailed notice (tlp, ) (Entered: 03/14/2011)
68 ORDER OF THREE−JUDGE DISTRICT COURT: Signed on 3/14/2011.Mailed notice(tlp, ) (Entered: 03/14/2011)
69 MINUTE entry before Honorable Virginia M. Kendall:Enter Final Order of Three−Judge District Court.Mailed notice (tsa, ) (Entered: 03/29/2011)
70 ORDER Entered by the Honorable Virginia M. Kendall on 3/29/2011.Mailed notice(tsa, ) (Entered: 03/29/2011)
71 MINUTE entry before Honorable Virginia M. Kendall: Status hearing set for 5/2/2011 at 10:00 AM.Mailed notice (tsa, ) (Entered: 04/07/2011)
72 MOTION by Plaintiff United States of America for leave to appear as Telephonically (Dean, Kerry) (Entered: 04/28/2011)
73 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for leave to appear 72 before Honorable Virginia M. Kendall on 5/2/2011 at 10:00 AM. (Dean, Kerry) (Entered: 04/28/2011)
74 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America for leave to appear as Telephonically 72 is granted. Mailed notice (tsa, ) (Entered: 04/29/2011)
75 MOTION by Defendant Thomas Dart for Authority to Retain Patricia L. Hardyman, Ph.D. (Gallagher, Daniel) (Entered: 04/29/2011)
76 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion for miscellaneous relief 75 before Honorable Virginia M. Kendall on 5/2/2011 at 10:00 AM. (Gallagher, Daniel) (Entered: 04/29/2011)
77 MOTION by Defendant Thomas Dart to Enter a Single Cumulative Prisoner Release Order (Gallagher, Daniel) (Entered: 04/29/2011)
78 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion for miscellaneous relief 77 before Honorable Virginia M. Kendall on 5/2/2011 at 10:00 AM. (Gallagher, Daniel) (Entered: 04/29/2011)
79 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 5/2/2011. Defendant Dart's motion 77 to enter single cumulative release order is taken under advisement. Defendant Dart's motion to retain Hardyman 75 , parties to submit an agreed proposed order. Status hearing set for 11/4/2011 at 10:00 AM.Advised in open court notice (tsa, ) (Entered: 05/03/2011)
80 MINUTE entry before Honorable Virginia M. Kendall:Motion 75 is granted. Advised in open court notice (tsa, ) (Entered: 05/03/2011)
81 EXHIBIT by Defendant Thomas Dart − Exhibit 1 regarding MOTION by Defendant Thomas Dart to Enter a Single Cumulative Prisoner Release Order 77 (Gallagher, Daniel) (Entered: 06/02/2011)
82 NOTICE by Thomas Dart re exhibit 81 1 to Motion to Enter a Single Cumulative Prisoner Release Order (Gallagher, Daniel) (Entered: 06/02/2011)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 9 of 25

06/08/2011 06/13/2011 06/13/2011 07/13/2011 07/13/2011 07/19/2011
10/18/2011 10/18/2011 10/24/2011
11/04/2011 04/02/2012 04/02/2012 04/02/2012 04/02/2012 04/02/2012 04/02/2012 04/02/2012 04/03/2012 04/04/2012

83 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendant Thomas Dart to Enter a Single Cumulative Prisoner Release Order 77 is denied. Mailed notice (tsa, ) (Entered: 06/09/2011)
84 MINUTE entry before Honorable Virginia M. Kendall: Enter agreed order to retain Patricia Hardyman, Ph.D. (For further detail see order) Mailed (vmj, ) (Entered: 06/16/2011)
85 AGREED Order Signed by the Honorable Virginia M. Kendall on 6/13/2011.(vmj, ) Modified on 7/7/2011 (vmj, ). (Entered: 06/16/2011)
86 MOTION by Defendant Thomas Dart for the Approval of Appointment of Retired Judges to Implement the Prisoner Release Order (Gallagher, Daniel) (Entered: 07/13/2011)
87 NOTICE of Motion by Daniel Francis Gallagher for presentment of motion for miscellaneous relief 86 before Honorable Virginia M. Kendall on 7/19/2011 at 09:00 AM. (Gallagher, Daniel) (Entered: 07/13/2011)
88 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendant Thomas Dart for the Approval of Appointment of Retired Judges to Implement the Prisoner Release Order 86 is granted. Advised in open court notice (tsa, ) (Entered: 07/19/2011)
89 MOTION by Plaintiff United States of America for leave to appear as Telephonically (Dean, Kerry) (Entered: 10/18/2011)
90 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for leave to appear 89 before Honorable Virginia M. Kendall on 11/4/2011 at 10:00 AM. (Dean, Kerry) (Entered: 10/18/2011)
91 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America for leave to appear as Telephonically 89 is granted. Contact numbers shall be submitted to the courtroom deputy at (312) 408−5153, the day before. Mailed notice (tsa, ) (Entered: 10/24/2011)
92 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 11/4/2011 and continued to 4/13/2012 at 09:00 AM.Advised in open court notice (tsa, ) (Entered: 03/30/2012)
93 MOTION by counsel for Defendant Thomas Dart to withdraw as attorney (OGrady, Paul) (Entered: 04/02/2012)
94 NOTICE of Motion by Paul A OGrady for presentment of motion to withdraw as attorney 93 before Honorable Virginia M. Kendall on 4/9/2012 at 09:00 AM. (OGrady, Paul) (Entered: 04/02/2012)
95 CONSENT MOTION by Plaintiff United States of America for continuance. (Jones, Michelle) (Text modified by clerk's office) (vmj, ). (Entered: 04/02/2012)
96 NOTICE of Motion by Michelle A Jones for presentment of motion to continue 95 before Honorable Virginia M. Kendall on 4/5/2012 at 09:00 AM. (Jones, Michelle) (Entered: 04/02/2012)
97 CERTIFICATE of Service by Michelle A Jones on behalf of United States of America regarding MOTION by Plaintiff United States of America to continue Status Hearing 95 (Jones, Michelle) (Entered: 04/02/2012)
98 MINUTE entry before Honorable Virginia M. Kendall:Notice of motion set for 4/5/2012 is stricken as not timely filed.Mailed notice (tsa, ) (Entered: 04/02/2012)
99 AMENDED NOTICE of Motion by Michelle A Jones for presentment of motion to continue 95 before Honorable Virginia M. Kendall on 4/9/2012 at 09:00 AM. (Jones, Michelle) (Text modified by clerk's office) (vmj, ). (Entered: 04/02/2012)
100 ATTORNEY Appearance for Defendant Thomas Dart by Dominick L Lanzito (Lanzito, Dominick) (Entered: 04/03/2012)
101 MINUTE entry before Honorable Virginia M. Kendall:Motion to continue 95 status hearing is granted. Status hearing reset to 5/15/2012 at 09:00 AM. Motion hearing set

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 10 of 25

04/04/2012
05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012 05/14/2012
05/14/2012 05/14/2012
05/14/2012 05/15/2012
06/26/2012
06/26/2012
06/29/2012
07/10/2012

for 4/9/2012 on this motion is hereby stricken.Mailed notice (tsa, ) (Entered: 04/04/2012)
102 MINUTE entry before Honorable Virginia M. Kendall: MOTION by counsel for Defendant Thomas Dart to withdraw as attorney 93 is granted. Daniel F. Gallagher is given leave to withdraw is appearance. Motion hearing set for 4/9/2012 on this motion is hereby stricken. Mailed notice (tsa, ) (Entered: 04/04/2012)
103 Monitor Susan W. McCampbell's Report No. 3 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
104 NOTICE by Thomas Dart re other 103 (O'Grady, Paul) (Entered: 05/14/2012)
105 Monitor Susan McCampbell's Report No. 4 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
106 NOTICE by Thomas Dart re other 105 (O'Grady, Paul) (Entered: 05/14/2012)
107 Monitor Harry Grenawitzke's Report No. 3 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
108 NOTICE by Thomas Dart re other 107 (O'Grady, Paul) (Entered: 05/14/2012)
109 Monitor Harry Grenawitzke's Report No. 4 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
110 NOTICE by Thomas Dart re other 109 (O'Grady, Paul) (Entered: 05/14/2012)
111 Monitor Ronald Shansky's Report No. 3 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
112 NOTICE by Thomas Dart re other 111 (O'Grady, Paul) (Entered: 05/14/2012)
113 Monitor Ronald Shansky's Report No. 4 by Thomas Dart (O'Grady, Paul) (Entered: 05/14/2012)
114 NOTICE by Thomas Dart re other 113 (O'Grady, Paul) (Entered: 05/14/2012)
115 Monitor Jeffrey L. Metzner's Report No. 4 by Thomas Dart (Attachments: # 1 Appendix 1, # 2 Appendix 2, # 3 Appendix 3, # 4 Appendix 4, # 5 Appendix 5, # 6 Appendix 6)(O'Grady, Paul) (Entered: 05/14/2012)
116 NOTICE by Thomas Dart re other 115 (O'Grady, Paul) (Entered: 05/14/2012)
117 Monitor Jeffrey L. Metzner's Report No. 3 by Thomas Dart (Attachments: # 1 Appendix 1, # 2 Appendix 2, # 3 Appendix 3, # 4 Appendix 4, # 5 Appendix 5, # 6 Appendix 6)(O'Grady, Paul) (Entered: 05/14/2012)
118 NOTICE by Thomas Dart re other 117 (O'Grady, Paul) (Entered: 05/14/2012)
119 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 5/15/2012. In Court hearing set for 9/20/2012 at 10:00 AM. Parties to turn in reports to the Court by 9/10/2012. Advised in open court notice (tsa, ) (Entered: 05/15/2012)
120 MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Todd H Stroger, Plaintiff United States of America to continue Status Hearing (Jones, Michelle) (Entered: 06/26/2012)
121 NOTICE of Motion by Michelle A Jones for presentment of motion to continue 120 before Honorable Virginia M. Kendall on 7/2/2012 at 09:00 AM. (Jones, Michelle) (Entered: 06/26/2012)
122 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Todd H Stroger, Plaintiff United States of America to continue Status Hearing 120 is granted. Status hearing reset for 10/9/2012 at 09:00 AM. Motion hearing set for 7/2/2012 on this motion is hereby stricken.Mailed notice (tsa, ) (Entered: 06/29/2012)
123 MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Todd H Stroger, Plaintiff United States of America to continue Status Hearing (Jones, Michelle) (Entered: 07/10/2012)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 11 of 25

07/10/2012
07/11/2012
08/09/2012 10/08/2012
10/08/2012 10/08/2012 10/08/2012 10/08/2012 10/08/2012 10/08/2012 10/08/2012 10/12/2012
10/22/2012 10/22/2012
10/23/2012
10/25/2012
10/26/2012
11/02/2012
11/02/2012
11/26/2012
12/03/2012

124 NOTICE of Motion by Michelle A Jones for presentment of motion to continue 123 before Honorable Virginia M. Kendall on 7/17/2012 at 09:00 AM. (Jones, Michelle) (Entered: 07/10/2012)
125 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Todd H Stroger, Plaintiff United States of America to continue Status Hearing 123 is granted. Status hearing reset to 10/29/2012 at 09:00 AM.Mailed notice (tsa, ) (Entered: 07/11/2012)
126 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 10/29/2012 at 10:00 AM.Mailed notice (tsa, ) (Entered: 08/09/2012)
127 MEMORANDUM by Thomas Dart. (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V)(O'Grady, Paul) (Docket text modified by clerk's office) (vmj, ). (Entered: 10/08/2012)
128 NOTICE by Thomas Dart re memorandum 127 . (O'Grady, Paul) (Text modified by clerk's office) (vmj) (Entered: 10/08/2012)
129 STATUS Report #5 by Thomas Dart (Attachments: # 1 Appendix I)(O'Grady, Paul) (Entered: 10/08/2012)
130 NOTICE by Thomas Dart re status report 129 (O'Grady, Paul) (Entered: 10/08/2012)
131 STATUS Report #5 by Thomas Dart (O'Grady, Paul) (Entered: 10/08/2012)
132 NOTICE by Thomas Dart re status report 131 (O'Grady, Paul) (Entered: 10/08/2012)
133 STATUS Report #5 by Thomas Dart (O'Grady, Paul) (Entered: 10/08/2012)
134 NOTICE by Thomas Dart re status report 133 (O'Grady, Paul) (Entered: 10/08/2012)
135 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 10/29/2012 at 03:00 PM. (TIME CHANGE)Mailed notice (tsa, ) (Entered: 10/12/2012)
136 MOTION by Defendant Thomas Dart for leave to appear telephonically. (O'Grady, Paul) (Text modified by clerk's office)(vmj, ). (Entered: 10/22/2012)
137 NOTICE of Motion by Paul A O'Grady for presentment of motion for leave to appear 136 before Honorable Virginia M. Kendall on 10/26/2012 at 09:00 AM. (O'Grady, Paul) (Entered: 10/22/2012)
138 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 10/29/2012 at 01:00 PM. (TIME CHANGE)Mailed notice (tsa, ) (Entered: 10/23/2012)
139 MINUTE entry before Honorable Virginia M. Kendall:Notice of motion set for 10/26/2012 is stricken. The Court does not entertain motions on Fridays. Mailed notice (tsa, ) (Entered: 10/25/2012)
140 MINUTE entry before Honorable Virginia M. Kendall:Motion for leave to appear 136 is granted. Counsel should contact the courtroom deputy at (312) 408−5153 with a contact number.Mailed notice (tsa, ) (Entered: 10/26/2012)
141 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 12/7/2012 at 01:30 PM. regarding medical and mental health issues.Mailed notice (tsa, ) (Entered: 11/02/2012)
142 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 12/14/2012 at 09:30 AM. regarding the issue of overcrowding. Mailed notice (tsa, ) (Entered: 11/02/2012)
143 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 12/14/2012 at 09:00 AM. (TIME CHANGE).Mailed notice (tsa, ) (Entered: 11/26/2012)
144 Monitor Jeffrey L. Metzner Report #6 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 12 of 25

12/03/2012 12/06/2012 12/07/2012 12/07/2012 12/07/2012
01/11/2013 01/25/2013 02/22/2013 02/25/2013
02/26/2013 03/06/2013 03/08/2013 03/08/2013 03/08/2013 03/08/2013 03/08/2013 04/25/2013

VI, # 7 Appendix VII)(O'Grady, Paul) (Entered: 12/03/2012)
145 NOTICE of filing by Thomas Dart re Monitor Jeffrey L. Metzner, M.D.'s Report No. 6 144 . (O'Grady, Paul) (Docket text modified by clerk's office) (vmj, ). (Entered: 12/03/2012)
146 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 12/7/2012 is stricken and reset to 12/10/2012 at 10:00 AM. regarding medical and health issues.Mailed notice (tsa, ) (Entered: 12/06/2012)
147 AGREED Emergency Motion for continuance. (Dean, Kerry) (Modified by clerk's office) (vmj, ). (Entered: 12/07/2012)
148 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to continue 147 before Honorable Virginia M. Kendall on 12/10/2012 at 09:00 AM. (Dean, Kerry) (Entered: 12/07/2012)
149 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America to continue hearing 147 is granted. In court hearing is stricken. Parties to contact the courtroom deputy at (312) 408−5153, via conference call, to set up a new date. Motion hearing set for 12/10/2012 on this motion is hereby stricken.Mailed notice (tsa, ) (Entered: 12/07/2012)
150 MINUTE entry before Honorable Virginia M. Kendall: In Court hearing set for 2/22/2013 at 10:00 AM. to discuss medical and mental health staffing.Mailed notice (tsa, ) (Entered: 01/11/2013)
151 MINUTE entry before Honorable Virginia M. Kendall: Conference set for 2/22/2013 at 01:00 PM. (time change)Mailed notice (tsa, ) (Entered: 01/25/2013)
152 MINUTE entry before Honorable Virginia M. Kendall: Settlement Conference set for 2/22/2013 at 01:30 PM. (TIME CHANGE)Mailed/Telephoned notice (tsa, ) (Entered: 02/22/2013)
153 MINUTE entry before Honorable Virginia M. Kendall:As set forth during the conference held on February 22, 2013, the parties are directed to submit position papers to the Court by March 1, 2013 regarding whether 725 ILCS 5/110 or any other Illinois statute prohibits Illinois state court judges from ordering electronic monitoring as a condition of release from pre−trial detention without also ordering the pre−trial detainee to pay a monetary bond. The parties are also directed to ensure that representatives for the judges for the Circuit Court of Cook County receive notice of this order so that they may submit a position paper if they so choose. Mailed notice (tsa, ) (Entered: 02/25/2013)
154 MINUTE entry before Honorable Virginia M. Kendall:Minute entry 153 is amended to reflect that the position papers are due 3/8/2013. The rest of the order shall stand.Mailed notice (tsa, ) (Entered: 02/26/2013)
155 Position Paper on Electronic Monitoring from Amicus (Law Office of the Cook County Public Defender) by Mark W. Solock (Solock, Mark) (Entered: 03/06/2013)
156 Position Paper STATEMENT by United States of America (Attachments: # 1 Exhibit July 2012 JAC Report, # 2 Exhibit Feb 25, 2013 Jail Population)(Dean, Kerry) (Entered: 03/08/2013)
157 Position Paper STATEMENT by Cook County Board of Commissioners, Cook County, Illinois, Toni Preckwinkle (Pechous, Donald) (Entered: 03/08/2013)
158 NOTICE by Cook County Board of Commissioners, Cook County, Illinois, Toni Preckwinkle re statement 157 (Pechous, Donald) (Entered: 03/08/2013)
159 Position Paper STATEMENT by Thomas Dart (Attachments: # 1 Exhibit 1, # 2 Exhibit 2)(O'Grady, Paul) (Entered: 03/08/2013)
160 NOTICE by Thomas Dart re statement 159 (O'Grady, Paul) (Entered: 03/08/2013)
161 Corrections Monitor Susan McCampbell's 6th Report by Thomas Dart (O'Grady, Paul) (Entered: 04/25/2013)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 13 of 25

04/25/2013 04/30/2013 05/08/2013 05/08/2013 05/14/2013 05/14/2013 05/20/2013
06/02/2013

162 NOTICE by Thomas Dart re other 161 (O'Grady, Paul) (Entered: 04/25/2013)
163 MINUTE entry before Honorable Virginia M. Kendall:Only one counsel of record for each party shall be present for the Court's visit to the Cook County Jail on Thursday May 2 at 8:30 a.m. Mailed notice (tsa, ) (Entered: 04/30/2013)
164 Monitor Harry Grenawitzke's Report #6 by Thomas Dart (O'Grady, Paul) (Entered: 05/08/2013)
165 NOTICE by Thomas Dart re other 164 (O'Grady, Paul) (Entered: 05/08/2013)
166 MOTION by Defendant Toni PreckwinkleAppointment of Special State's Attorney Counsel (Attachments: # 1 Exhibit A−Cook County Board Resolution)(Piers, Matthew) (Entered: 05/14/2013)
167 NOTICE of Motion by Matthew J. Piers for presentment of motion for miscellaneous relief 166 before Honorable Virginia M. Kendall on 5/20/2013 at 09:00 AM. (Piers, Matthew) (Entered: 05/14/2013)
168 MINUTE entry before Honorable Virginia M. Kendall:Motion by defendant Preckwinkle for miscellaneous relief 166 is entered and briefed as follows: Responses due by 6/10/2013. Replies due by 6/17/2013. Ruling will be made by mail. The plaintiff should follow the above briefing schedule. Status hearing set for 6/27/2013 at 09:00 AM.Mailed notice (tsa, ) (Entered: 05/20/2013)
169 TRANSCRIPT OF PROCEEDINGS held on 1/7/2011 before the Honorable Richard A. Posner. Court Reporter Contact Information: april.metzler@sbcglobal.net (419) 787−1832 − cell.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

06/02/2013

Redaction Request due 6/24/2013. Redacted Transcript Deadline set for 7/3/2013. Release of Transcript Restriction set for 9/3/2013. (rp, ) (Entered: 06/04/2013)
170 TRANSCRIPT OF PROCEEDINGS held on 3/1/2011 before the Honorable Richard A. Posner. Court Reporter Contact Information: april.metzler@sbcglobal.net (419) 787−1832 − cell.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

06/07/2013 06/10/2013 06/10/2013 06/10/2013
06/10/2013

Redaction Request due 6/24/2013. Redacted Transcript Deadline set for 7/3/2013. Release of Transcript Restriction set for 9/3/2013. (rp, ) (Entered: 06/04/2013)
171 RESPONSE by Plaintiff United States of America to motion for miscellaneous relief 166 (Dean, Kerry) (Entered: 06/07/2013)
172 RESPONSE by Defendant Thomas Dart to motion for miscellaneous relief 166 (O'Grady, Paul) (Entered: 06/10/2013)
173 NOTICE by Thomas Dart re Response 172 (O'Grady, Paul) (Entered: 06/10/2013)
174 RESPONSE by Cook County Board of Commissioners, Cook County, Illinoisin Opposition to MOTION by Defendant Toni PreckwinkleAppointment of Special State's Attorney Counsel 166 (Pechous, Donald) (Entered: 06/10/2013)
175 NOTICE by Cook County Board of Commissioners, Cook County, Illinois re response in opposition to motion 174 (Pechous, Donald) (Entered: 06/10/2013)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 14 of 25

06/10/2013 06/13/2013
06/13/2013 06/17/2013 06/27/2013
06/28/2013

176 ATTORNEY Appearance for Defendants Cook County Board of Commissioners, Cook County, Illinois by Paul Anthony Castiglione (Castiglione, Paul) (Entered: 06/10/2013)
177 Monitor Jeffrey L. Metzner's Report No. 7 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix VI, # 7 Appendix VII, # 8 Appendix VIII, # 9 Appendix IX, # 10 Appendix X, # 11 Appendix XI, # 12 Appendix XII)(O'Grady, Paul) (Entered: 06/13/2013)
178 NOTICE by Thomas Dart re other, 177 (O'Grady, Paul) (Entered: 06/13/2013)
179 REPLY by Defendant Toni Preckwinkle to Response 172 , response in opposition to motion 174 (Attachments: # 1 Exhibit 1−Resolution, # 2 Notice of Filing)(Piers, Matthew) (Entered: 06/17/2013)
180 MINUTE entry before Honorable Virginia M. Kendall:Status hearing held on 6/27/2013. Supplemental filings by the parties are due by 7/8/2013. Position papers to the Monitors reports by 8/1/2013. Hearing regarding the Monitors reports is set for 9/11/2013 at 10:00 AM.Advised in open court notice (tsa, ) (Entered: 06/27/2013)
181 TRANSCRIPT OF PROCEEDINGS held on 06/27/2013 before the Honorable Virginia M. Kendall. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, (312) 435−6047, Gayle_McGuigan@ilnd.uscourts.gov.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

07/08/2013 07/08/2013 07/08/2013 07/08/2013 07/08/2013
07/22/2013 07/22/2013 07/30/2013

Redaction Request due 7/19/2013. Redacted Transcript Deadline set for 7/29/2013. Release of Transcript Restriction set for 9/26/2013. (McGuigan, Gale) (Entered: 06/28/2013)
182 RESPONSE by Defendant Thomas Dart to Response 172 Supplemental Response To Cook County Board President's Petition for Appointment of Special State's Attorney Counsel To Represent Her In This Matter (O'Grady, Paul) (Entered: 07/08/2013)
183 NOTICE by Thomas Dart re Response 182 (O'Grady, Paul) (Entered: 07/08/2013)
184 RESPONSE by Cook County, Illinoisin Opposition to MOTION by Defendant Toni PreckwinkleAppointment of Special State's Attorney Counsel 166 Supplemental (Attachments: # 1 Exhibit Transcript)(Pechous, Donald) (Entered: 07/08/2013)
185 NOTICE by Cook County, Illinois re response in opposition to motion 184 (Pechous, Donald) (Entered: 07/08/2013)
186 REPLY by Defendant Toni Preckwinkle to Response 172 , response in opposition to motion 174 Supplemental Filing of Cook County Board President Toni Preckwinkle in Support of her Petition for the Appointment of Special State's Attorneys (Attachments: # 1 Exhibit A − Performance Management Ordinance, # 2 Exhibit B − AG Letter, # 3 Notice of Filing)(Piers, Matthew) (Entered: 07/08/2013)
187 MOTION by Defendant Thomas Dart to strike Monitor Dr. Shansky's Report (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3)(O'Grady, Paul) (Entered: 07/22/2013)
188 NOTICE of Motion by Paul A O'Grady for presentment of motion to strike 187 before Honorable Virginia M. Kendall on 7/30/2013 at 09:00 AM. (O'Grady, Paul) (Entered: 07/22/2013)
189 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendant Thomas Dart to strike Monitor Dr. Shansky's Report 187 is entered and continued to 9/11/2013 at 10:00 AM. Position papers are due 7/30/2013.Advised in open court notice (tsa, ) (Entered: 07/30/2013)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 15 of 25

08/30/2013 08/30/2013 08/30/2013 08/30/2013 08/30/2013 08/30/2013 08/30/2013 08/30/2013
09/09/2013
09/10/2013 09/10/2013 09/11/2013
09/18/2013 09/18/2013 10/01/2013
10/02/2013

190 Monitor Shansky's 7th Report by Thomas Dart (Attachments: # 1 Part 2)(O'Grady, Paul) (Entered: 08/30/2013)
191 NOTICE by Thomas Dart re other 190 (O'Grady, Paul) (Entered: 08/30/2013)
192 Position Paper by United States of America re Status of Compliance (Dean, Kerry) (Entered: 08/30/2013)
193 NOTICE by United States of America re other 192 (Dean, Kerry) (Entered: 08/30/2013)
194 Sheriff Dart's Position Paper Regarding Monitor's Reports by Thomas Dart (O'Grady, Paul) (Entered: 08/30/2013)
195 NOTICE by Thomas Dart re other 194 (O'Grady, Paul) (Entered: 08/30/2013)
196 MOTION by Plaintiff United States of America to continue 9/11/13 Status Hearing (Dean, Kerry) (Entered: 08/30/2013)
197 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to continue 196 before Honorable Virginia M. Kendall on 9/10/2013 at 09:00 AM. (Dean, Kerry) (Entered: 08/30/2013)
198 MINUTE entry before Honorable Virginia M. Kendall:Motion to continue 196 is denied. Ms. Dean is given leave to appear by telephone at the status hearing. Mailed notice (tsa, ) (Entered: 09/09/2013)
199 MOTION by Defendant Thomas Dart to strike Dr. Shansky's Report (Attachments: # 1 Exhibit 1, # 2 Exhibit 2, # 3 Exhibit 3)(O'Grady, Paul) (Entered: 09/10/2013)
200 NOTICE of Motion by Paul A O'Grady for presentment of (O'Grady, Paul) (Entered: 09/10/2013)
201 MINUTE entry before Honorable Virginia M. Kendall:Motion hearing held on 9/11/2013, regarding MOTION by Defendant Thomas Dart to strike Dr. Shansky's Report. 199 . Defendant's oral motion to withdraw the motion to strike is granted and the motion is terminated as moot. Response to report is to be filed by 9/18/13. Judicial staff mailed notice (gl, ) (Entered: 09/12/2013)
202 RESPONSE by Defendants Cook County Board of Commissioners, Toni Preckwinkle to Monitors' Reports (Pechous, Donald) (Entered: 09/18/2013)
203 NOTICE by Cook County Board of Commissioners, Toni Preckwinkle re Response 202 (Pechous, Donald) (Entered: 09/18/2013)
204 MINUTE entry before Honorable Virginia M. Kendall: MOTION by Defendant Toni Preckwinkle Appointment of Special State's Attorney Counsel 166 is denied for the reasons stated in open court at the last status hearing on 9/11/2013. (tsa, ) (Entered: 10/01/2013)
205 TRANSCRIPT OF PROCEEDINGS held on 09/11/2013 before the Honorable Virginia M. Kendall. − Status. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, (312) 435−6047, Gayle_McGuigan@ilnd.uscourts.gov.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

10/07/2013

Redaction Request due 10/23/2013. Redacted Transcript Deadline set for 11/4/2013. Release of Transcript Restriction set for 12/31/2013. (McGuigan, Gale) (Entered: 10/02/2013)
206 GENERAL ORDER 13−0018 dated 10/7/2013: IT IS HEREBY ORDERED, effective October 1, 2013, that all civil litigation involving as a party the United States of America, is immediately suspended, postponed and held in abeyance continuing for a period of fourteen (14) days from the date of entry of this General Order (For Further

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 16 of 25

10/17/2013
12/04/2013
12/04/2013 12/04/2013 12/04/2013 12/04/2013 12/04/2013 12/19/2013 02/11/2014 02/11/2014 02/14/2014
03/05/2014 03/05/2014 03/10/2014 03/10/2014

Details See Attached Order). Signed by Chief Judge Castillo. Mailed notice (jmp, ) (Entered: 10/07/2013)
207 GENERAL ORDER 13−0019 dated 10/17/13: IT IS THEREFORE ORDERED, that the stay entered by General Order 13−0018 is hereby lifted, and any and all deadlines in the affected civil litigation (whether established by order, rule, or agreement), including but not limited to any scheduled discovery and pleading dates, are extended by 28 days. The Court warns litigants that this General Order does not purport to affect rights to or deadlines concerning appeal from any decision of this Court. Any litigant affected by this General Order may see relief from the order by motion. Trial dates in the affected cases will stand, although they may need to be adjusted in individual cases to account for the extension of other dates. The Court may, in any particular case, vary the effect or operation of this General Order by a separate ruling. (For Further Details See Attached Order). Signed by Chief Judge Castillo. (et, ) (Entered: 10/17/2013)
208 Monitor Jeffery L. Metzner M.D.'s Report No. 8 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix VI, # 7 Appendix VII, # 8 Appendix VIII, # 9 Appendix IX, # 10 Appendix X, # 11 Appendix XI, # 12 Appendix XII, # 13 Appendix XIII, # 14 Appendix XIV)(O'Grady, Paul) (Entered: 12/04/2013)
209 NOTICE by Thomas Dart re other, 208 Monitor Jeffery L. Metzner M.D.'s Report No. 8 (O'Grady, Paul) (Entered: 12/04/2013)
210 Monitor Susan W. McCampbell's Report No. 7 by Thomas Dart (O'Grady, Paul) (Entered: 12/04/2013)
211 NOTICE by Thomas Dart re other 210 Monitor Susan W. McCampbell's Report No. 7 (O'Grady, Paul) (Entered: 12/04/2013)
212 Monitor Harry Grenawitzke's Report No. 7 by Thomas Dart (O'Grady, Paul) (Entered: 12/04/2013)
213 NOTICE by Thomas Dart re other 212 Monitor Harry E. Grenawitzke's Report No. 7 (O'Grady, Paul) (Entered: 12/04/2013)
214 LETTER from Donald Conwell dated 12/6/2013. (jmp, ) (Entered: 12/19/2013)
215 MOTION by Plaintiff United States of America for order Appointing New Medical Monitor (Attachments: # 1 Exhibit A − Porsa CV)(Dean, Kerry) (Entered: 02/11/2014)
216 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for order 215 before Honorable Virginia M. Kendall on 3/11/2014 at 09:00 AM. (Dean, Kerry) (Entered: 02/11/2014)
217 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America for order Appointing New Medical Monitor 215 is granted. The Court appoints Esmaeil Porsa, MD, MPH as Medical Monitor. Status hearing is set for 9/16/2014 @ 9:00 a.mMailed notice (tsa, ) (Entered: 02/14/2014)
218 MOTION by Defendants Cook County Board of Commissioners, Toni Preckwinkle Parties' Joint Motion for Modification of the Prisoner Release Order (Pechous, Donald) (Entered: 03/05/2014)
219 NOTICE of Motion by Donald J. Pechous for presentment of motion for miscellaneous relief 218 before Honorable Virginia M. Kendall on 3/13/2014 at 09:00 AM. (Pechous, Donald) (Entered: 03/05/2014)
220 ATTORNEY Appearance for Defendant Thomas Dart by Daniel P Duffy (Duffy, Daniel) (Entered: 03/10/2014)
221 MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Toni Preckwinkle to reassign case pursuant to Local Rule 40.4 (Hudson v. Cook County, 13 cv 08752) (Attachments: # 1 Exhibit A − Complaint in USA v. Cook County, # 2 Exhibit B − Amended Complaint − Hudson v. Cook County 13 cv 08752, # 3 Exhibit C − Monitor'Susan'W.'McCampbells'Report'No.'7', # 4 Exhibit D − Motion for Preliminary Injunction)(Duffy, Daniel) (Entered: 03/10/2014)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 17 of 25

03/10/2014 03/12/2014
03/13/2014 03/13/2014 03/13/2014 03/17/2014
03/19/2014 03/26/2014 03/26/2014 04/21/2014 04/21/2014 05/27/2014 05/27/2014 05/27/2014
05/27/2014 05/27/2014 05/27/2014 06/02/2014

222 NOTICE of Motion by Daniel P Duffy for presentment of motion to reassign case,, 221 before Honorable Virginia M. Kendall on 3/12/2014 at 09:00 AM. (Duffy, Daniel) (Entered: 03/10/2014)
223 MINUTE entry before the Honorable Virginia M. Kendall: Motion hearing held on 3/12/2014. On defendants' joint motion for reassignment and consolidation pursuant to Local Rule 40.4 221 , response due by 3/14/2014. Only if necessary, reply due by 3/19/2014; said motion is taken under advisement. Mailed notice (am) (Entered: 03/12/2014)
224 MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Toni Preckwinkle to withdraw motion to reassign case,, 221 (Duffy, Daniel) (Entered: 03/13/2014)
225 MINUTE entry before the Honorable Virginia M. Kendall:Motion for modification of prisoner release orders 218 is taken under advisement.Mailed notice (tsa, ) (Entered: 03/13/2014)
226 NOTICE of Motion by Daniel P Duffy for presentment of motion to withdraw, motion for relief 224 before Honorable Virginia M. Kendall on 3/19/2014 at 09:00 AM. (Duffy, Daniel) (Entered: 03/13/2014)
227 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Toni Preckwinkle to reassign case pursuant to Local Rule 40.4 (Hudson v. Cook County, 13 cv 08752) 221 is withdrawn. MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Thomas Dart, Toni Preckwinkle to withdraw motion to reassign case 221 224 is withdrawn. Motion hearing set for 3/19/2014 on this motion is hereby stricken. Mailed notice (tsa, ) (Entered: 03/17/2014)
228 ORDER: Enter order to reconvene the three−judge panel. Signed by the Honorable Diane P. Wood on 3/19/2014.Mailed notice(tsa, ) (Docket Text Modified by Clerks' Office on 4/28/2015) (lw, ). (Entered: 03/20/2014)
229 NOTICE by Dominick L Lanzito of Change of Address (Lanzito, Dominick) (Entered: 03/26/2014)
230 NOTICE by Paul A O'Grady of Change of Address (O'Grady, Paul) (Entered: 03/26/2014)
231 Monitor Susan McCampbell's Report No. 8 by Thomas Dart (O'Grady, Paul) (Entered: 04/21/2014)
232 NOTICE by Thomas Dart re other 231 Monitor Susan McCampbell's Report No. 8 (O'Grady, Paul) (Entered: 04/21/2014)
233 Monitor Harry E. Grenawitzke's Report No 8 by Thomas Dart (O'Grady, Paul) (Entered: 05/27/2014)
234 NOTICE by Thomas Dart re other 233 Monitor Harry E. Grenawitzke's Report No 8 (Final Report) (O'Grady, Paul) (Entered: 05/27/2014)
235 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix VI, # 7 Affidavit VII, # 8 Appendix VIII, # 9 Appendix VIIII, # 10 Exhibit A, # 11 Exhibit B)(O'Grady, Paul) (Entered: 05/27/2014)
236 NOTICE by Thomas Dart re other, 235 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 (O'Grady, Paul) (Entered: 05/27/2014)
237 MOTION by Defendant Thomas Dart to strike other, 235 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 (O'Grady, Paul) (Entered: 05/27/2014)
238 NOTICE of Motion by Paul A O'Grady for presentment of motion to strike, motion for relief 237 before Honorable Virginia M. Kendall on 6/2/2014 at 09:00 AM. (O'Grady, Paul) (Entered: 05/27/2014)
239 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by Defendant Thomas Dart to strike other, 235 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 237 is granted with leave to refile after reviewal.Mailed notice (tsa, ) (Entered: 06/02/2014)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 18 of 25

06/11/2014 06/11/2014 06/13/2014 06/13/2014 06/13/2014 06/16/2014
06/17/2014 06/18/2014

240 MOTION by Defendant Thomas DartTo Lift Confidentiality Provision of Agreed Order For A Limited Purpose (O'Grady, Paul) (Entered: 06/11/2014)
241 NOTICE of Motion by Paul A O'Grady for presentment of motion for miscellaneous relief 240 before Honorable Virginia M. Kendall on 6/17/2014 at 09:00 AM. (O'Grady, Paul) (Entered: 06/11/2014)
242 RESPONSE by Plaintiff United States of America to motion for miscellaneous relief 240 (Dean, Kerry) (Entered: 06/13/2014)
243 MOTION by Plaintiff United States of America for leave to appear as Telephonically (Dean, Kerry) (Entered: 06/13/2014)
244 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for leave to appear 243 before Honorable Virginia M. Kendall on 6/17/2014 at 09:00 AM. (Dean, Kerry) (Entered: 06/13/2014)
245 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America for leave to appear Telephonically 243 is granted. Counsel shall provide a contact number prior to the telephonic appearance at (312) 408−5153.Mailed notice (tsa, ) (Entered: 06/16/2014)
246 MINUTE entry before the Honorable Virginia M. Kendall:Defendant's motion 240 to lift confidentiality provision of agreed order for a limited purpose is taken under advisement. Telephoned/Advised in open court notice (tsa, ) (Entered: 06/17/2014)
247 TRANSCRIPT OF PROCEEDINGS held on 6/17/14 before the Honorable Virginia M. Kendall. Court Reporter Contact Information: Lisa Breiter, lisabreiter@comcast.net, 630.885.0455.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

06/23/2014
06/23/2014 07/03/2014
07/03/2014 07/09/2014 07/29/2014 07/29/2014 08/13/2014 08/13/2014

Redaction Request due 7/9/2014. Redacted Transcript Deadline set for 7/21/2014. Release of Transcript Restriction set for 9/16/2014. (Renke, Laura) (Entered: 06/18/2014)
248 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix V, # 6 Appendix VI, # 7 Appendix VII, # 8 Appendix VIII, # 9 Appendix IX, # 10 Exhibit A, # 11 Exhibit B)(O'Grady, Paul) (Entered: 06/23/2014)
249 NOTICE by Thomas Dart re other, 248 Monitor Jeffrey L. Metzner, M.D.'s Report No 9 (O'Grady, Paul) (Entered: 06/23/2014)
250 Defendants' Supplemental Brief In Support Of Their Motion To Lift Confidentiality Provision Of Agreed Order For A Limited Purpose by Thomas Dart (Attachments: # 1 Exhibit 1)(O'Grady, Paul) (Entered: 07/03/2014)
251 NOTICE by Thomas Dart re other 250 (O'Grady, Paul) (Entered: 07/03/2014)
252 MINUTE entry before the Honorable Virginia M. Kendall: Status hearing set for 8/5/2014 at 10:30 AM.Mailed notice (tsa, ) (Entered: 07/09/2014)
253 ATTORNEY Appearance for Plaintiff United States of America by Cathleen Siobhan Trainor (Trainor, Cathleen) (Entered: 07/29/2014)
254 ATTORNEY Appearance for Plaintiff United States of America by Kyle E. Smiddie (Smiddie, Kyle) (Entered: 07/29/2014)
255 Monitor Esmaeil Porsa's Report No. 8 by Thomas Dart (O'Grady, Paul) (Entered: 08/13/2014)
256 NOTICE by Thomas Dart re other 255 (O'Grady, Paul) (Entered: 08/13/2014)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 19 of 25

09/16/2014 09/25/2014 09/25/2014 09/30/2014
10/07/2014
11/04/2014 11/04/2014 11/13/2014 11/13/2014 11/20/2014 12/08/2014
12/08/2014 01/06/2015 01/06/2015 01/08/2015 02/03/2015 02/03/2015 03/11/2015
03/17/2015 03/17/2015

257 MINUTE entry before the Honorable Virginia M. Kendall:Status hearing held on 9/16/2014 (in chambers). In chamber hearing set for 2/11/2015 at 10:00 AM. with the monitors.Mailed notice (tsa, ) (Entered: 09/17/2014)
258 MOTION by counsel for Defendants Cook County Board of Commissioners, Cook County, Illinois, Todd H Stroger to withdraw as attorney (Cavanaugh, Colleen) (Entered: 09/25/2014)
259 NOTICE of Motion by Colleen Bernadette Cavanaugh for presentment of motion to withdraw as attorney 258 before Honorable Virginia M. Kendall on 10/8/2014 at 09:00 AM. (Cavanaugh, Colleen) (Entered: 09/25/2014)
260 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by counsel for Defendants Cook County Board of Commissioners, Cook County, Illinois, Todd H Stroger to withdraw as attorney 258 is granted. Colleen Cavanaugh is given leave to withdraw her appearance. Motion hearing set for 10/8/2014 on this motion is hereby stricken. Mailed notice (tsa, ) (Entered: 09/30/2014)
261 MINUTE entry before the Honorable Virginia M. Kendall:Defendant's motion to lift confidentiality provision of agreed order 240 is denied as moot as the case has been consolidated with Hudson v. Preckwinkle et al. (13 C 8752)Mailed notice (tsa, ) (Entered: 10/07/2014)
262 Monitor Susan McCampbell's Report No. 9 by Thomas Dart (O'Grady, Paul) (Entered: 11/04/2014)
263 NOTICE by Thomas Dart re other 262 (O'Grady, Paul) (Entered: 11/04/2014)
264 Monitor Harry E. Grenawitzke's Report No 9 by Thomas Dart (O'Grady, Paul) (Entered: 11/13/2014)
265 NOTICE by Thomas Dart re other 264 (O'Grady, Paul) (Entered: 11/13/2014)
268 NOTICE of Contempt of a Court Order. (rm, ) (Entered: 12/19/2014)
266 Monitor Jeffrey L. Metzner, M.D.'s Report No 10 by Thomas Dart (Attachments: # 1 Appendix I, # 2 Appendix II, # 3 Appendix III, # 4 Appendix IV, # 5 Appendix IX, # 6 Exhibit A, # 7 Exhibit B, # 8 Exhibit C, # 9 Exhibit D)(O'Grady, Paul) (Entered: 12/08/2014)
267 NOTICE by Thomas Dart re other, 266 Monitor Jeffrey L. Metzner, M.D.'s Report No 10 (O'Grady, Paul) (Entered: 12/08/2014)
269 MINUTE entry before the Honorable Virginia M. Kendall:The Meeting with the Monitors will commence at 9:30 a.m.Mailed notice (tsa, ) (Entered: 01/06/2015)
270 MINUTE entry before the Honorable Virginia M. Kendall:Minute entry 269 is clarified to include the date, 1/8/2015 at 9:30 a.m.Mailed notice (tsa, ) (Entered: 01/06/2015)
271 MINUTE entry before the Honorable Virginia M. Kendall:In chambers hearing set for for 2/11/2015 is stricken. The Court will reset the hearing by a future minute order.Mailed notice (tsa, ) (Entered: 01/08/2015)
272 Monitor Esmaeil Porsa's Report No. 9 by Thomas Dart (O'Grady, Paul) (Entered: 02/03/2015)
273 NOTICE by Thomas Dart re other 272 Monitor Esmaeil Porsa's Report No. 9 (O'Grady, Paul) (Entered: 02/03/2015)
274 MINUTE entry before the Honorable Virginia M. Kendall:Oral argument will be heard on the pending motion to modify the PLRA Panel's Release Order on March 19, 2015 at 10:30 a.m. in the Seventh Circuit Courtroom on the 27th floor.Mailed notice (tsa, ) (Entered: 03/11/2015)
275 Status Report to the Court by Thomas Dart (Attachments: # 1 Exhibit A)(O'Grady, Paul) (Entered: 03/17/2015)
276 NOTICE by Thomas Dart re other 275 Status Report to the Court (O'Grady, Paul) (Entered: 03/17/2015)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 20 of 25

03/19/2015 03/19/2015
03/25/2015 03/26/2015

277 MINUTE entry before the Honorable Virginia M. Kendall:In court oral argument hearing held on 3/19/2015. Parties shall submit a proposed order on or before 3/25/2015. Advised in open court notice (tsa, ) (Entered: 03/19/2015)
278 MINUTE entry before the Honorable Virginia M. Kendall:Minute entry 277 is amended to include the following: Defendants Cook County Board of Commissioners, Toni Preckwinkle Parties' Joint Motion for Modification of the Prisoner Release Order 218 is taken under advisement. The rest of the order shall stand. Advised in open court notice (tsa, ) (Entered: 03/19/2015)
279 Jointly Proposed Modified Prisoner Release Order by United States of America (Dean, Kerry) (Entered: 03/25/2015)
280 TRANSCRIPT OF PROCEEDINGS held on 03/19/2015 before Court of Appeals Judge Richard A. Posner, Judge Sharon Johnson Coleman, and Judge Virginia M. Kendall. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, (312) 435−6047, Gayle_McGuigan@ilnd.uscourts.gov.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

03/31/2015 04/10/2015 04/10/2015 04/14/2015 04/15/2015 04/16/2015
04/27/2015 06/02/2015 06/02/2015 06/02/2015 06/02/2015 06/02/2015

Redaction Request due 4/16/2015. Redacted Transcript Deadline set for 4/27/2015. Release of Transcript Restriction set for 6/24/2015. (McGuigan, Gale) (Entered: 03/26/2015)
281 ORDER of the Three−Judge Prisoner Litigation Reform Act Panel. Entered by the Three−Judge Panel on 3/31/2015.Mailed notice(tsa, ) (Entered: 03/31/2015)
282 MOTION by Plaintiff United States of America to withdraw 218 Joint Motion for Modification of the Prisoner Release Order (Dean, Kerry) (Entered: 04/10/2015)
283 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to withdraw 282 before Honorable Virginia M. Kendall on 4/16/2015 at 09:00 AM. (Dean, Kerry) (Entered: 04/10/2015)
284 MINUTE entry before the Honorable Virginia M. Kendall: Monitors Meeting set for 4/16/2015 at 02:00 PM in chambers.Mailed notice (tsa, ) (Entered: 04/14/2015)
285 MINUTE entry before the Honorable Virginia M. Kendall: MOTION by Plaintiff United States of America to withdraw 218 Joint Motion for Modification of the Prisoner Release Order 282 is granted. Mailed notice (tsa, ) (Entered: 04/15/2015)
286 MINUTE entry before the Honorable Virginia M. Kendall:Monitors' meeting held on 4/16/2015. Monitors' reports to be sent out for review by 5/14/2015. Responses to reports due by 6/15/2015. Reports to be filed on our before 6/22/2015. Court hearing regarding the Monitors' reports set for 7/8/2015 at 10:00 AM.Mailed notice (tsa, ) (Entered: 04/17/2015)
287 MINUTE entry before the Honorable Virginia M. Kendall: In Court hearing set for 7/8/2015 at 11:00 AM. (TIME CHANGE)Mailed notice (tsa, ) (Entered: 04/27/2015)
288 Monitor Harry E. Grenawitzke's Report No 10 by Thomas Dart (O'Grady, Paul) (Entered: 06/02/2015)
289 NOTICE by Thomas Dart re other 288 Monitor Harry E. Grenawitzke's Report No 10 (O'Grady, Paul) (Entered: 06/02/2015)
290 Monitor Susan McCampbell's Report No. 10 by Thomas Dart (O'Grady, Paul) (Entered: 06/02/2015)
291 NOTICE by Thomas Dart re other 290 Monitor Susan McCampbell's Report No. 10 (O'Grady, Paul) (Entered: 06/02/2015)
292 MOTION by Defendants Cook County Board of Commissioners, Cook County, Illinois, Toni PreckwinkleUnopposed Motion to Conclude Sections III.F & III.G of the

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 21 of 25

06/02/2015 06/09/2015
06/22/2015 06/22/2015 06/22/2015
06/22/2015 07/02/2015 07/02/2015 07/08/2015 07/31/2015 12/08/2015 12/08/2015 01/27/2016 01/27/2016 04/05/2016 04/08/2016 04/08/2016 04/08/2016 04/11/2016 04/11/2016

Agreed Order (Pechous, Donald) (Entered: 06/02/2015)
293 NOTICE of Motion by Donald J. Pechous for presentment of motion for miscellaneous relief 292 before Honorable Virginia M. Kendall on 6/9/2015 at 09:00 AM. (Pechous, Donald) (Entered: 06/02/2015)
294 MINUTE entry before the Honorable Virginia M. Kendall:Unopposed motion by Defendants Cook County Board of Commissioners, Cook County, Illinois, Toni Preckwinkle Motion to Conclude Sections III.F & III.G of the Agreed Order 292 is granted. Draft order to follow. Mailed notice (tsa, ) (Entered: 06/09/2015)
295 Monitor Jeffrey L. Metzner, M.D.'s Final Report by Thomas Dart (Attachments: # 1 Appendix, # 2 Appendix, # 3 Appendix, # 4 Appendix, # 5 Appendix, # 6 Appendix, # 7 Attachment I, # 8 Attachment II)(O'Grady, Paul) (Entered: 06/22/2015)
296 NOTICE by Thomas Dart re other, 295 Monitor Jeffrey L. Metzner, M.D.'s Final Report (O'Grady, Paul) (Entered: 06/22/2015)
297 ORDER: Enter order. It is hereby ordered that Section III.F: Fire and Life Safety and III.G: Sanitation and Environmental Conditions of the Agreed Order are terminated as they pertain to Cook County and its Department of Facilities Management. All other provisions of the Agreed Order remain in full force and effect until further order of this Court. Signed by the Honorable Virginia M. Kendall on 6/22/2015. Mailed notice (aee, ) (Entered: 06/25/2015)
298 ORDER: Signed by the Honorable Virginia M. Kendall on 6/22/2015. Mailed notice (aee, ) (Entered: 06/25/2015)
299 Monitor Report of Dr. Esmaeil Porsa by United States of America (Dean, Kerry) (Entered: 07/02/2015)
300 NOTICE by United States of America re other 299 Filing of Monitor's Report (Dean, Kerry) (Entered: 07/02/2015)
301 MINUTE entry before the Honorable Virginia M. Kendall:In court hearing held on 7/8/2015.Advised in open court notice (tsa, ) (Entered: 07/08/2015)
302 Enter ORDER. Signed by the Honorable Virginia M. Kendall on 7/31/2015.Mailed notice(tsa, ) (Entered: 07/31/2015)
303 Monitor Jeffrey L. Metzner, M.D.'s Report No 11 by Thomas Dart (O'Grady, Paul) (Entered: 12/08/2015)
304 NOTICE by Thomas Dart re other 303 Monitor Jeffrey L. Metzner, M.D.'s Report No 11 (O'Grady, Paul) (Entered: 12/08/2015)
305 Monitor Esmaeil Porsa's Report No. 11 by Thomas Dart (O'Grady, Paul) (Entered: 01/27/2016)
306 NOTICE by Thomas Dart re other 305 (O'Grady, Paul) (Entered: 01/27/2016)
307 MOTION by Petitioner Barbara Lyons for Leave to take the Deposition of Harry Grenawitzke (Nicholas, Adele D.) (Entered: 04/05/2016)
308 MINUTE entry before the Honorable Virginia M. Kendall. Petitioner's Motion for leave to take deposition 307 is stricken for failure to provide notice. Mailed notice. (lk, ) (Entered: 04/08/2016)
309 MOTION by Petitioner Barbara Lyons for Leave to take the Deposition of Harry Grenawitzke (Nicholas, Adele D.) (Entered: 04/08/2016)
310 NOTICE of Motion by Adele D. Nicholas for presentment of motion for miscellaneous relief 309 before Honorable Virginia M. Kendall on 4/13/2016 at 09:00 AM. (Nicholas, Adele D.) (Entered: 04/08/2016)
311 Uncontested MOTION by Plaintiff United States of America for leave to appear as Telephonically Uncontested (Dean, Kerry) (Entered: 04/11/2016)
312 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for leave to appear 311 before Honorable Virginia M. Kendall on 4/13/2016 at 09:00 AM. (Dean,

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 22 of 25

04/11/2016 04/12/2016
04/13/2016
04/14/2016 04/14/2016 04/28/2016 05/18/2016 05/18/2016 05/20/2016 05/20/2016 06/10/2016 06/13/2016
06/23/2016 06/23/2016 07/21/2016 07/21/2016 10/06/2016
10/06/2016
10/12/2016
10/25/2016

Kerry) (Entered: 04/11/2016)
313 ATTORNEY Appearance for Defendant Thomas Dart by Darren K Angell (Angell, Darren) (Entered: 04/11/2016)
314 MINUTE entry before the Honorable Virginia M. Kendall. Plaintiff's Uncontested Motion for leave to appear telephonically 311 is granted. Mailed notice. (lk, ) (Entered: 04/12/2016)
315 MINUTE entry before the Honorable Virginia M. Kendall. Motion hearing held on 4/13/2016 regarding Petitioner's Motion for Leave to take the Deposition of Harry Grenawitzke 309 . Petitioner's Motion for Leave to take the Deposition of Harry Grenawitzke 309 is denied. Mailed notice. (lk, ) (Entered: 04/13/2016)
316 Monitor Harry E. Grenawitzke's Report No 11 by Thomas Dart (O'Grady, Paul) (Entered: 04/14/2016)
317 NOTICE by Thomas Dart re other 316 Monitor Harry E. Grenawitzke's Report No 11 (O'Grady, Paul) (Entered: 04/14/2016)
318 MINUTE entry before the Honorable Virginia M. Kendall. In Court hearing set for 5/4/2016 at 2:00 PM. Mailed notice (lk, ) (Entered: 04/28/2016)
319 Monitor Susan McCampbell's Report No. 11 by Thomas Dart (O'Grady, Paul) (Entered: 05/18/2016)
320 NOTICE by Thomas Dart re other 319 Monitor Susan McCampbell's Report No. 11 (O'Grady, Paul) (Entered: 05/18/2016)
321 STIPULATION regarding order 13 Amendment to Agreed Order (Dean, Kerry) (Entered: 05/20/2016)
322 NOTICE by United States of America re stipulation 321 Amendment to Agreed Order (Dean, Kerry) (Entered: 05/20/2016)
323 MINUTE entry before the Honorable Virginia M. Kendall. In Court hearing set for 10/13/2016 at 4:00 PM. Mailed notice (lk, ) (Entered: 06/10/2016)
324 ATTORNEY Appearance for Defendants Cook County Board of Commissioners, Cook County, Illinois by Anthony E. Zecchin (Zecchin, Anthony) (Entered: 06/13/2016)
325 Monitor Esmaeil Porsa's Report No. 12 by Thomas Dart (O'Grady, Paul) (Entered: 06/23/2016)
326 NOTICE by Thomas Dart re other 325 Monitor Esmaeil Porsa's Report No. 12 (O'Grady, Paul) (Entered: 06/23/2016)
327 Monitor Harry E. Grenawitzke's Final Report No. 12 by Thomas Dart (O'Grady, Paul) (Entered: 07/21/2016)
328 NOTICE by Thomas Dart re other 327 Monitor Harry E. Grenawitzke's Final Report No. 12 (O'Grady, Paul) (Entered: 07/21/2016)
329 MINUTE entry before the Honorable Virginia M. Kendall. In Court hearing set for 10/13/2016 is reset for 11/2/2016 at 1:00 PM. Mailed notice (lk, ) (Entered: 10/06/2016)
330 MINUTE entry before the Honorable Virginia M. Kendall. Due to clerical error, In Court hearing set for 10/13/2016 was stricken. In Court hearing set for 10/13/2016 at 4:00 PM stands. Mailed notice (lk, ) (Entered: 10/06/2016)
331 MINUTE entry before the Honorable Virginia M. Kendall. In Court hearing set for 10/13/2016 at 1:00 PM. (TIME CHANGE ONLY) Mailed notice (lk, ) (Entered: 10/12/2016)
332 TRANSCRIPT OF PROCEEDINGS held on 10/13/2016 before the Honorable Virginia M. Kendall. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, (312) 435−6047, Gayle_McGuigan@ilnd.uscourts.gov.

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 23 of 25

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

11/14/2016 11/14/2016 11/23/2016 11/23/2016 12/02/2016 12/02/2016 12/12/2016 12/12/2016 12/22/2016 12/22/2016 01/09/2017 01/09/2017
01/09/2017
01/09/2017 01/09/2017 01/11/2017
01/11/2017
01/19/2017
01/24/2017

Redaction Request due 11/15/2016. Redacted Transcript Deadline set for 11/28/2016. Release of Transcript Restriction set for 1/23/2017. (McGuigan, Gale) (Entered: 10/25/2016)
333 Monitor Jeffrey L. Metzner, M.D.'s Report No 12 by Thomas Dart (O'Grady, Paul) (Entered: 11/14/2016)
334 NOTICE by Thomas Dart re other 333 Monitor Jeffrey L. Metzner, M.D.'s Report No 12 (O'Grady, Paul) (Entered: 11/14/2016)
335 Monitor Susan McCampbell's Final Report No. 12 by Thomas Dart (O'Grady, Paul) (Entered: 11/23/2016)
336 NOTICE by Thomas Dart re other 335 Monitor Susan McCampbell's Final Report No. 12 (O'Grady, Paul) (Entered: 11/23/2016)
337 STATUS Report by Cook County, Illinois (Zecchin, Anthony) (Entered: 12/02/2016)
338 NOTICE by Cook County, Illinois re status report 337 (Zecchin, Anthony) (Entered: 12/02/2016)
339 Monitor Jeffrey L. Metzner, M.D.'s Final Report by Thomas Dart (O'Grady, Paul) (Entered: 12/12/2016)
340 NOTICE by Thomas Dart re other 339 Monitor Jeffrey L. Metzner, M.D.'s Final Report (O'Grady, Paul) (Entered: 12/12/2016)
341 STATUS Report to the Court by Thomas Dart (O'Grady, Paul) (Entered: 12/22/2016)
342 NOTICE by Thomas Dart re status report 341 to the Court (O'Grady, Paul) (Entered: 12/22/2016)
343 MOTION by Plaintiff United States of America to Terminate Agreed Order Sections III.A, C, F−H as to Sheriff (Dean, Kerry) (Entered: 01/09/2017)
344 NOTICE of Motion by Kerry Krentler Dean for presentment of motion for miscellaneous relief 343 before Honorable Virginia M. Kendall on 1/12/2017 at 10:00 AM. (Dean, Kerry) (Entered: 01/09/2017)
345 MINUTE entry before the Honorable Virginia M. Kendall. Motion Hearing set for 1/12/2017 at 9:00 AM. (TIME CHANGE ONLY) Mailed notice (lk, ) (Entered: 01/09/2017)
346 Monitor Harry E. Grenawitzke's Final Tour Report No 13 by Thomas Dart (O'Grady, Paul) (Entered: 01/09/2017)
347 NOTICE by Thomas Dart re other 346 Monitor Harry E. Grenawitzke's Final Tour Report No. 13 (O'Grady, Paul) (Entered: 01/09/2017)
348 MINUTE entry before the Honorable Virginia M. Kendall. By agreement and availability of parties, Motion Hearing set for 1/12/2017 is reset for 1/24/2017 at 9:00 AM. Mailed notice (lk, ) (Entered: 01/11/2017)
349 MINUTE entry before the Honorable Virginia M. Kendall. Due to conflict of schedule for counsel, Motion hearing set for 1/24/2017 is reset for 1/26/2017 at 9:00 AM. Mailed notice (lk, ) (Entered: 01/11/2017)
350 MINUTE entry before the Honorable Virginia M. Kendall. Motion Hearing set for 1/24/2017 is reset for 1/27/2017 at 10:45 AM. Mailed notice (lk, ) (Entered: 01/19/2017)
351 Monitor Esmaeil Porsa's Report No. 13 by Thomas Dart (O'Grady, Paul) (Entered: 01/24/2017)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 24 of 25

01/24/2017 01/25/2017 01/27/2017

352 NOTICE by Thomas Dart re other 351 Monitor Esmaeil Porsa's Report No. 13 (O'Grady, Paul) (Entered: 01/24/2017)
353 MINUTE entry before the Honorable Virginia M. Kendall. Motion Hearing set for 1/27/2017 at 3:00 PM. (TIME CHANGE ONLY) Mailed notice (lk, ) (Entered: 01/25/2017)
354 TRANSCRIPT OF PROCEEDINGS held on 01/27/2017 before the Honorable Virginia M. Kendall. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, gayle.court.transcripts@gmail.com, (312) 435−6047.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

01/30/2017
05/02/2017 05/02/2017 05/18/2017 05/18/2017 05/30/2017 06/09/2017 06/19/2017

Redaction Request due 2/17/2017. Redacted Transcript Deadline set for 2/27/2017. Release of Transcript Restriction set for 4/27/2017. (McGuigan, Gale) (Entered: 01/27/2017)
355 MINUTE entry before the Honorable Virginia M. Kendall. Motion hearing held on 1/30/2017. Parties' Joint Motion to terminate sections III.A, III.C, III.F, III.G & III.H of the agreed order as to Sheriff Thomas Dart 343 is granted. Mailed notice (lk, ) (Entered: 01/30/2017)
356 Monitor Jeffrey L. Metzner, M.D.'s Report No. 14 by Thomas Dart (O'Grady, Paul) (Entered: 05/02/2017)
357 NOTICE by Thomas Dart re other 356 Monitor Jeffrey L. Metzner, M.D.'s Report No. 14 (O'Grady, Paul) (Entered: 05/02/2017)
358 MOTION by Plaintiff United States of America to dismiss Sheriff (Dean, Kerry) (Entered: 05/18/2017)
359 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to dismiss 358 before Honorable Virginia M. Kendall on 6/8/2017 at 02:00 PM. (Dean, Kerry) (Entered: 05/18/2017)
360 MINUTE entry before the Honorable Virginia M. Kendall. By agreement of parties, Motion hearing set for 6/8/2017 is reset for 6/9/2017 at 10:00 AM. Mailed notice. (lk, ) (Entered: 05/30/2017)
361 MINUTE entry before the Honorable Virginia M. Kendall. Motion hearing held on 6/9/2017. Plaintiff's Unopposed Motion to dismiss Sheriff Dart 358 from the Consent Decree entered into in 2010 is granted. Mailed notice (lk, ) (Entered: 06/12/2017)
362 TRANSCRIPT OF PROCEEDINGS held on 06/09/2017 before the Honorable Virginia M. Kendall. Court Reporter Contact Information: Gayle A. McGuigan, CSR, RMR, CRR, Gayle_McGuigan@ilnd.uscourts.gov, (312) 435−6047.

IMPORTANT: The transcript may be viewed at the court's public terminal or purchased through the Court Reporter/Transcriber before the deadline for Release of Transcript Restriction. After that date it may be obtained through the Court Reporter/Transcriber or PACER. For further information on the redaction process, see the Court's web site at www.ilnd.uscourts.gov under Quick Links select Policy Regarding the Availability of Transcripts of Court Proceedings.

07/11/2017 07/11/2017

Redaction Request due 7/10/2017. Redacted Transcript Deadline set for 7/20/2017. Release of Transcript Restriction set for 9/18/2017. (McGuigan, Gale) (Entered: 06/19/2017)
363 MEDICAL MONITOR DR. ESMAEIL PORSAS FOURTEENTH REPORT by Cook County, Illinois (Pechous, Donald) (Entered: 07/11/2017)
364 NOTICE by Cook County, Illinois re other 363 MEDICAL MONITOR DR. ESMAEIL PORSAS FOURTEENTH REPORT (Pechous, Donald) (Entered: 07/11/2017)

Case: 1:10-cv-2946 As of: 03/17/2020 01:28 PM CDT 25 of 25

12/27/2017 12/27/2017 12/27/2017
01/17/2018
05/03/2018 05/03/2018 06/05/2018 06/05/2018 06/12/2018 06/12/2018 06/12/2018 06/12/2018 06/26/2018

365 Monitor Esmaeil Porsa's Report No. 15 by Cook County, Illinois (O'Grady, Paul) (Entered: 12/27/2017)
366 NOTICE by Cook County, Illinois re other 365 Monitor Esmaeil Porsa's Report No. 15 (O'Grady, Paul) (Entered: 12/27/2017)
367 NOTICE OF EMAIL NOTIFICATION FAILURE, for document # 366 , 365 sent to Attorney Daniel P Duffy returned as: Unknown Address Error. Mailed to attorney Daniel P Duffy a letter re: bounce back email and a Notification of Change of Address form. Notices have been set to No. Counsel must email the Clerk's Office at Docketing_ILND@uscourts.gov when a Notification of Change of Address has been filed to ensure electronic notification is reset. (ek, ) (Entered: 12/28/2017)
368 MAIL RETURNED, for document # 367 sent to Daniel P. Duffy returned as undeliverable, return to sender. No new contact information received; therefore future mailings will not be sent until a new address is provided to the Clerk's Office using a Notification of Change of Address or Pro Se Appearance form (ek, ) (Entered: 01/18/2018)
369 Monitor's Report of Jeffrey L. Metzner, M.D. by Cook County Board of Commissioners, Cook County, Illinois November 2017 (Zecchin, Anthony) (Entered: 05/03/2018)
370 NOTICE by Cook County Board of Commissioners, Cook County, Illinois re other 369 Monitor's Report of Jeffrey L. Metzner, M.D. − November 2017 (Zecchin, Anthony) (Entered: 05/03/2018)
371 Monitor's Report by United States of America re: Mental Health Services (Dean, Kerry) (Entered: 06/05/2018)
372 NOTICE by United States of America re other 371 Metzner Mental Health Report (Dean, Kerry) (Entered: 06/05/2018)
373 Medical Monitoring Report by United States of America for Dr. Esmaeil Porsa (Dean, Kerry) (Entered: 06/12/2018)
374 NOTICE by United States of America re other 373 Filing Medical Monitoring Report (Dean, Kerry) (Entered: 06/12/2018)
375 MOTION by Plaintiff United States of America to dismiss and Terminate Agreed Order (Dean, Kerry) (Entered: 06/12/2018)
376 NOTICE of Motion by Kerry Krentler Dean for presentment of motion to dismiss 375 before Honorable Virginia M. Kendall on 6/26/2018 at 09:30 AM. (Dean, Kerry) (Entered: 06/12/2018)
377 MINUTE entry before the Honorable Virginia M. Kendall. Motion hearing held on 6/26/2018. Parties' Joint Motion to Dismiss and Terminate Remaining Sections of the Agreed Order 375 is granted. Cook County has achieved the conditions required to terminate all of its responsibilities under the Agreed Order and Case is dismissed. Civil case terminated. Mailed notice (lk, ) (Entered: 06/27/2018)

 
 u.s. Department of Justice
Civil Rights Division

Office of the Assistant Attorney General

Washington, D. C. 20530

JUL 1 1 2008
Todd H. Stroger Cook County Board President 118 N. Clark Street Room 537 Chicago, IL 60602
Thomas Dart Cook County Sheriff Richard J. Daley Center 50 W. Washington Street Room 704 Chicago, IL 60602
Re: Cook County Jail Chicago, Illinois
Dear President Stroger and Sheriff Dart:
We write to report the findings of the investigation of Civil Rights Division and the United States Attorney's Office into conditions at the Cook County Jail ("CCJ"). On February 16, 2007, we notified the Cook County Board of Commissioners ("County") of our intent to conduct an investigation of CCJ pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. § 1997. As we noted, CRIPA gives the Department of Justice authority to seek a remedy for a pattern or practice of conduct that violates the constitutional rights of inmates in adult detention and correctional facilities.
On June 18-22, 2007, and July 23-27, 2007, we conducted on-site inspections at CCJ with expert consultants in corrections, use of force, custodial medical and mental health care, fire safety, and sanitation. 1 We interviewed
lOur fire safety and sanitation experts accompanied us only on the July on-site visit.

-2-
administrative staff r security staff r medical and mental health staff r facilities management staff r training staff r and inmates. Before r during r and after our visits r we reviewed an extensive number of documents r including policies and procedures r incident reports r use of force reports r investigative reports r inmate grievances r disciplinary reports r unit logsr orientation materials r medical records r and staff training materials. In keeping with ?ur pledge of transparency and to provide technical assistance where appropriate r we conveyed our preliminary findings to CCJ officials and legal counsel for the County and Sheriffrs Office at the close of our July 2007 site visit.
During our July 27 r 2007 exit meeting r and by. letter dated August 3 r 2007 r we notified CCJ officials of life-threatening deficiencies in sanitation and safety measures at CCJ. In particular r we indicated that inadequate emergency key precautions and grossly unsanitary conditions in certain tiers re.sul ted in a serious and immediate risk of harm to inmates. On August 6 r 2007 r counsel for the Sheriffrs Office promptly responded by indicating that a number of corrective measures were being implemented to address our concerns. 2
We commend the staff at CCJ for their helpful and professional conduct throughout the course of the investigation. We received complete cooperation with our investigation r which is particularly appreciated given that CCJ is the countryr s largest single-site jail. CCJ provided us with unfettered access to records and personnel r and responded to our requests r both before and during our on-site visits r in a transparent and forthcoming manner. We also appreciate the Countyr s and the Sheriffrs Officers receptiveness to our consultants r on-site recommendations. AccordinglYr we have every reason to believe that the County and the Sheriffrs Office are committed to remedying all known deficiencies at CCJ.
Consistent with the statutory requirements of CRIPA r we now write to advise you of the findings of our investigation r the facts supporting them r and the minimum remedial steps that are necessary to address the deficiencies we have identified.

2

Counsel for the Sheriffrs Office provided additional

information regarding corrective measures in a letter and

attachments on October 5 r 2007. We commend the Sheriffrs Office

on these reported advances and view them as progress toward

improved conditions at CCJ. We look forward to the opportunity

to verify the improvements.

! --. - -- .

-3-
42 § U.S.C. 1997b. As described more fully below, we conclude that certain conditions at CCJ violate the constitutional rights of inmates. In particular, we find that inmates confined at CCJ are not adequately protected from harm, including physical harm from excessive use of force by staff and inmate-on-inmate violence due to inadequate supervision. In addition, we find that inmates do not receive adequate medical and mental health care, including proper suicide prevention. CCJ inmates also face serious risks posed by inadequate fire safety precautions. Finally, we find that environmental and sanitation deficiencies at CCJ result in unconstitutional living conditions for inmates.
As discussed in this let.ter, these conditions have r~s.ulted in serious harm to CCJ inmates. Three inmates' committed suicide at CCJ in the first four months of 2008. During our investigation, we identified multiple preventable inmate deaths and a preventable amputation, due to inadequate medical care. In 2006, separate incidents of unchecked inmate violence resulted in two inmate deaths. In a one-week period during March 2007, CCJ
documented 35 inmate fights, required 27 uses of force,and found
46 weapons within the facility. The myriad of serious incidents summarized here, and others discussed herein, indicates that CCJ is not adequately providing .for the safety and weil-being of the inmates.
I . BACKGROUND
Located on approximately 96 acres in Chicago, Illinois, CCJ is the largest single-site county jail in the United States. 3 CCJ has a daily population of approximately 9,800 adult male and female inmates, most of whom are awaiting trial in the criminal court system. In 2006, CCJ admitted 99,663 inmates. CCJ is staffed by approximately 3,800 sworn law enforcement officers and civilian employees.
CCJ is separated into 11 semi-autonomous divisions,4 each with its own superintendent and standard operating procedures. The majority of the male inmates are housed in three maximum-security divisions (Divisions I, IX, and X), three medium-security male divisions (Divisions V, VI, and XI), and one

3

http://www.cookcountysheriff.org/doc/html/facility.htm1

4 The divisions are designated by number, one through eleven. There is no Division VII. The Receiving Classification Diagnostic Center essentially functions as a separate division, with its own superintendent.

-4-
medium and minimum-security dormitory division (Division II) . Female inmates of mixed security classifications are housed on Division III, which also contains male and female medical and mental health tiers, and Division IV. Division VIII contains Cermak Health Services and the Residential Treatment Unit. The Receiving, Classification, and Diagnostics Center (URCDC") is located in the lower level of Division V and handles reception, classification, and discharge for all CCJ inmates. Division I is the oldest building, dating from 1929, and Division XI is the newest, opened in 1995. The divisions range in rated capacityS from 353 inmates'in Division III to 1,536 in Division XI.
Allcorrections and security fUTlctionsatCCJare administered by the Cook County Department of Corrections ("CCDOC") under the Cook County Sheriff. Health care services at CCJ are provided by Cermak Health Services of Cook County (UCermak"), which is part of the Cook County Bureau of Health. While the health services staff are County employees who are responsible for the health care of all CCJ inmates, they are not employed by, or responsible to, the Cook County Sheriff or CCDOC. Although health care and security issues require a degree of separation in all correctional facilities, as discussed in more detail below, the complete division between corrections and health care operations at CCJ results in serious administrative problems, including increased frustration, communication breakdowns, and finger-pointing. Regardless of the administrative division, Cook County and the Cook County Sheriff's Office are responsible for the well-being of CCJ inmates, including providing adequate care for inmates' serious medical and mental health care needs.
In 1982, the County entered into a consent decree in Duran v. Dart, No. 74-C-2949 (N.D. Ill. Apr. 9, 1982) (UDuran Consent Decree") to resolve a class action lawsuit filed by pre-trial detainees, pursuant to 42 U.S.C. § 1983, regarding overcrowding of CCJ. The Duran Consent Decree, as amended, is still under the jurisdiction of the United States District Court for the Northern District of Illinois. The decree focuses on overcrowding, but does contain some provisions governing staffing, food service, personal hygiene, the law library, visitation, physical exercise, classification, environmental health, and emergencies. CCJ's compliance with the Duran Consent Decree is monitored by the John Howard Association. CCJ is also governed by multiple other

5

Actual capacity is often much lower than the rated

capacity due to cells that are inoperable as a result of

maintenance problems.

-5-
agreements and orders, such as Harrington v. DeVito, No. 74-C3290 (N.D. Ill. Oct. 19, 1978) (mental health care) and Jackson v. Sheriff of Cook County, No. 06-CV-493 (N.D. Ill. July 16, 2007) (STD testing). Despite the existence of these court orders, a myriad of unconstitutional practices remain at CCJ. The current court orders applicable to CCJ either do not include specific provisions governing the constitutional concerns raised below regarding protection from harm, inadequate medical and mental health care, fire safety, and sanitation, or have not resulted in lasting or effective corrective measures.
II. LEGAL STANDARDS
CRIPA authorizes the Attorney General to seek injunctive relief to enforce the constitutional rights of inmates subject to a pattern or practice of unconstitutional conditions in jails and prisons. 42 U.S.C. § 1997. In defining the scope of jail inmates' Eighth and Fourteenth Amendment rights, the Supreme Court has held that corrections officials must take reasonable steps to guarantee inmates' safety and provide ~humane condit;i.ons" of confinement. Farmer v. Brennan, 511 U.S. 825, 832 (1994); Bell v. Wolfish, 441 U.S. 520 (1979) (holding pre-trial detainees protected by Fourteenth Amendment); Cavalieri v. Shepard, 321 F.3d 616, 620 (7th eire 2003). Providing ~humane conditions" requires that a corrections system must ~take reasonable measures to guarantee the safety of the inmates" and satisfy inmates' basic needs, such as their need for medical care, food, clothing, and shelter. Farmer at 832. The protection of pre-trial detainees' rights under the due process clause of the Fourteenth Amendment is ~at least as great as the Eighth Amendment protections available to a convicted prisoner." City of Revere v. Mass. Gen. Hosp., 463 U.S. 239, 244 (1983).
When a jurisdiction takes a person into custody and holds him there against his will, the Constitution imposes upon it a corresponding duty to assume some responsibility for his safety and general well-being. County of Sacramento v. Lewis, 523 U.S. 833, 851 (1998) (citing DeShaney v. Winnebago County Dept. of Social Servs., 489 U.S. 189, 199-200 (1989)).
The duties imposed and rights conferred by the Eighth Amendment apply to the unreasonable risk of serious harm, even if such harm has not yet occurred:
We have great difficulty agreeing that prison authorities may not be deliberately indifferent to an inmate's current health problems but may ignore a condition of confinement that is sure or very likely to

1-

- 6-

cause serious illness and needless suffering the next

week or month or year

. That the Eighth Amendment

protects against future harm to inmates is not a novel

proposition. The Amendment, as we have said, requires

that inmates be furnished with the basic human needs,

one of which is reasonable safety.

Helling v. McKinney, 509 U.S. 25, 33 (1993) (internal citations and quotations omitted); Woodward v. Correctional Medical Services of Illinois, Inc., 368 F.3d 917, 927 (7th Cir. 2004) (citing Farmer, 511 U.S. at 842).

The "Eighth ,A.mencimentp:r:-()hipition against cruel and.unusuaJ punishment has been expanded under the Due Process Clause of the Fourteenth Amendment to impose upon both federal and state correctional officers and officials the obligation to take reasonable steps to protect inmates from violence at the hands of other inmates." Goka v. Bobbitt, 862 F.2d 646, 649-50 (7th Cir. 1988); see also Hudson v. Palmer, 468 U.S. 517, 526-27 (1984); Swofford v. Mandrell, 969 F.2d 547, 549 (7th Cir. 1992); Anderson v. Gutschenritter, 836 F.2d 346, 349 (7th Cir. 1988); Archie v. City of Racine, 847 F.2d 1211, 1222-23 (7th Cir. 1988) (en banc) .

The Eighth Amendment forbids excessive physical force against prisoners. Hudson v. McMillian, 503 U.S. I, 9 (1992). This is true even when the use of force does not result in significant injury. Id. A jailor prison official who inflicts force maliciously and sadistically to cause an inmate harm violates the Eighth Amendment. Id.

Inmates also have the right to be free from retaliation for engaging in constitutionally protected conduct, such as complaining about conditions of confinement. Walker v. Thompson, 288 F.3d 1005 (7th Cir. 2002); DeWalt v. Carter, 224 F.3d 607, 618 (7th Cir. 2000) ("An act taken in retaliation for the exercise of a constitutionally protected right violates the Constitution") .

While low staffing levels do not, by themselves, constitute due process violations, they provide support for a conclusion that the inmates are treated "recklessly or with deliberate indifference" to their safety. Swofford, 969 F.2d at 549. Similarly, although overcrowding is not a per se constitutional violation, overcrowding resulting in bunking multiple inmates in a single cell without adequate safety, space, sanitation, bedding, or opportunities for activities outside the cells can amount to unconstitutional conditions of confinement. French v. Owens, 777 F.2d 1250, 1252-53 (7th Cir. 1985) (holding that

-7-
overcrowding was unconstitutional where it led to unsafe and unsanitary conditions) i Wellman v. Faulkner, 715 F.2d 269 (7th Cir. 1983) (holding that prison was unconstitutionally overcrowded) i see also Nami v. Fauver, 82 F.3d 63, 67 (3d Cir. 1996) (holding that double-bunking coupled with extended in-cell periods despite safety hazards could constitute a constitutional violation) .
A jailer~s deliberate indifference to an inmate's serious medical needs violates the Eighth Amendment. Estelle v. Gamble, 429 U.S. 97, 102 (1976) i Maggert v.Hanks, 131 F.3d 670, 671 (7th Cir. 1997). "Deliberate indifference" involves both an objective and a subj ective component. The obj ective c()mponent ismet if the deprivation is "sufficiently serious." Farmer, 511 U.S. at 834. Prison officials may not refuse, unreasonably delay, or intentionally interfere with medical treatment for incarcerated individuals. Hudson v. McHugh, 148 F.3d 859 (7th Cir. 1998) ("[T]his is the prototypical case of deliberate indifference, an inmate with a potentially serious problem repeatedly requesting medical aid, receiving none, and then suffering a serious injury.") i Zentmyer v. Kendall County, 220 F.3d 805 (7th Cir. 2000). "Deliberate indifference can be evidenced by 'repeated examples of negligent acts which disclose a pattern of conduct by the prison medical staff' or it can be demonstrated by 'proving there are such systemic and gross deficiencies in staffing, facilities, equipment, or procedures that the inmate population is effectively denied access to adequate medical care.'" Wellman, 715 F.2d at 271 (citing Ramos v. Lamm, 639 F.2d 559, 575 (10th Cir. 1980), cert. denied, 450 U.S. 1041 (1981)). Jail officials also may not provide an easier but less efficacious course of treatment nor may they offer only cursory medical care when the need for more serious treatment is obvious. See Estelle, 429 U.S. at 104-05. Failure to provide medication can violate the duty to provide adequate medical care to address serious medical needs. See, e.g., Zentmyer, 200 F.3d at 811.
The County's obligation to provide adequate medical care includes a duty to provide adequate mental health care. Farmer, 511 U.S. at 832i Sanville v. McCaughtry, 266 F.3d 724, 734 (7th Cir. 2001) (noting that a mentally ill inmate's condition was "objectively, sufficiently serious" such that incarcerating him under conditions that posed a substantial risk that he would commit suicide subjected him to cruel and unusual punishment) . In addressing the constitutionally minimal standards for mental health care in a jailor prison, the Seventh Circuit notes: "When a claim is based upon the failure to prevent harm, in order to satisfy the first element the plaintiff must show that the inmate was 'incarcerated under conditions posing a substantial

-8-
risk of serious harm.'" Id. (citing Farmer" 511 U.S. at 832) i see also Estate of Novack v. County of Wood, 226 F.3d 525, 529 (7th Cir. 2000) i Estate of Cole v. Fromm, 94 F.3d 254, 261 (7th Cir. 1996). Where a jail's ~actual practice" towards treatment of mentally ill inmates in general is clearly inadequate, the facility may be held to be ~on notice" at the time of an inmate's incarceration that there is a substantial risk of deprivation of necessary care. Woodward, 368 F.3d at 927 (practice of inadequate employee training, incomplete intake screening, and inadequate suicide watch constituted deliberate indifference).
The risk of suicide is an ~objectively serious harm" from which inmates have a right to protection, under the deliberate indifference standard. Matos v. O'Sullivan, 335 F.3d 553, 557 (7th Cir. 2003). Inadequate suicide prevention may constitute deliberate indifference. 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) i Woodward, 368 F.3d at 929 (fact that no previous suicides occurred in jail did not negate possibility of a practice of deliberate indifference toward suicidal detainees) i Cavalieri, 321 F.3d at 620 (holding that the right to be free from deliberate indifference to suicide was clearly established) .
Inmates are constitutionally entitled to environmental conditions that do not pose serious risks to health and safety, including deficient sanitation, inadequate fire safety, inadequate ventilation, and pest infestation. Vinning-EI v. Long, 482 F.3d 923, 924-25 (7th Cir. 2007) (holding that deliberate indifference could be established by inference from conditions, including floor covered with water, broken toilet, blood and feces smeared along wall, no mattress to sleep on) i Gillis v. Litscher, 468 F.3d 488, 568 (7th'Cir. 2006) (~[A] state must provide. . reasonably adequate ventilation, sanitation, bedding, hygienic materials, and utilities (i.e., hot and cold water, light, heat, plumbing) .") i Board v. Farnham, 394 F.3d 469 (7th Cir. 2005) (requiring adequate ventilation) i Isby v. Clark, 100 F.3d 502, 506 (7th Cir. 1996) (~Sanitation, we assume, includes things like odors and general cleanliness around the cell.") (emphasis in original) i French, 777 F.2d at 1257 (holding that fire safety is a ~legitimate" concern under the Eighth Amendment) i Antonelli v. Sheahan, 81 F.3d 1422, 1432 (7th Cir. 1995) (requiring adequate pest control) .
In addition, detainees have a right to be free of bodily restraints, such as shackles or a restraint chair, unless the facility demonstrates a legitimate penological or medical reason for the restraint. Murphy v. Walker, 51 F.3d 714, 718· (7th Cir.

-9-
1995). Where restraints are used, the inmate should be properly monitored and the length of restraint-time should be limited to ensure the inmate's safety. French, 777 F.2d at 1253-54. Restraints impos~d by correctional officers that are medically unjustifiable and have no adequate security rationale infringe on an inmate's due process rights. Wells v. Franzen, 777 F.2d 1258, 1263 (7th Cir. 1985) (restraint of a suicidal inmate).
III. FINDINGS
We find that CCJ fails to adequately protect inmates from harm and serious risk of harm from staff and other inmates; fails to provide inmates with adequate medicalandmental health ~are; fails to provide adequate suicide prevention; fails to provide adequate fire safety precautions; and fails to provide safe and sanitary environmental conditions.
A. INADEQUATE PROTECTION FROM HARM
Corrections officials must take reasonable steps to guarantee inmates' safety and provide "humane conditions" of confinement. Farmer, 511 U.S.-at 832. Providing humane conditions requires that a corrections system must satisfy inmates' basic needs, such as their need for safety. Additionally, jail officials have a duty to take reasonable steps to protect inmates from physical abuse.
To ensure reasonably safe conditions, officials must take measures to prevent the use of unnecessary and inappropriate force by staff. Officials must also take reasonable steps to protect inmates from violence at the hands of other inmates. In addition, officials must provide adequate systems to investigate incidents of harm, including staff misconduct and alleged physical abuse of inmates. Finally, a jail has an obligation to protect vulnerable inmates from harm, such as those who are at risk of suicide or at risk from other inmates. For the reasons set forth below, CCJ fails to meet constitutional standards in all of these regards.
1. Inappropriate and Excessive Use of Force
Although the violence present in a correctional setting necessarily permits the appropriate use of force, the Constitution forbids exce"ssive physical force against inmates. A determination of whether force is used appropriately requires an evaluation of the need for the use of force, the relationship between that need and the amount of force used, the seriousness of the threat reasonably believed to exist, and efforts made to temper the severity of a forceful response. Hudson v. McMillian,

- 10 -
503 U.S. 1, 7 (1992). Generally accepted correctional practices provide that appropriate uses of force in a given circumstance should include a continuum of interventions, and that the amount of force used should not be disproportionate to the threat posed by the inmate. Absent exigent circ~mstances,lesserforms of intervention, such as issuing disciplinary infractions or passive escorts, should be used or considered prior to more serious and forceful interventions.
We found that inmates at CCJ are regularly subjected to inappropriate and excessive uses of physical force. CCJ officers too often respond to inmates' verbal insults or failure to follow instructioTls byphysicallystr:ikil1g inmat:~s, most oft:epwith the active assistance of other officers, ~ven when the inmate presents no threat to anyone's safety or the security of the facility. Moreover, even in cases in which the initial use of force is reasonable, officers sometimes continue to engage in physical force after the inmate has been brought under control or is effectively restrained.
A top security administrator frankly acknowledged to us the existence of U a culture of abusing inmates" when he came to CCJ in October 2006. While senior management has taken steps to reduce the use of force, such as requiring Use of Force Reports and by subjecting these documents to greater scrutiny, the excessive and inappropriate use of force has not been brought under dontrol. We believe that, despite management's efforts, a culture still exists at CCJ in which the excessive and inappropriate use of physical force is too often tolerated.
Our investigation included an intensive examination of documents provided by CCJ concerning the incidents listed below and a host of others occurring between January 2006 and July 2007. We also conducted a great many staff and inmate int~rviews. In some cases, our findings of inappropriate or excessive uses of force are in accord with CCJ's own conclusions.
a. Use of Force in Response to Verbal Altercations
The use of force, while sometimes necessary in a corrections setting, must be appropriate to the given circumstances and proportionate to the threat posed. A verbal taunt from an inmate to an officer is a rule violation and may appropriately result in disciplinary action, but it should not require a physical response. As the examples below demonstrate, verbal altercations with inmates too often provoke physical responses from CCJ officers:

- 11 -
1. In July 2007, following his hour of exercise, Alberto p.6 refused to return to his cell and a female officer locked the cell doors while Alberto remained outside. He called the officer a nb----." When Alberto came out with his property to be moved to disciplinary segregation for insulting the officer, he was beaten by a number of officers. One officer later told Alberto that he had tried to stop the beating, but he just ndidn't have enough juice" (apparently explaining his inability to control the other officers). CCJ records confirm that Alberto was transferred to segregation and taken to Cermak for his injuries.
2. In June 2007, Dennis L. returned to his cellblock after a psychological evaluation. An officer refused to give Dennis a dinner tray. Dennis got into a verbal altercation with the officer and threw a cup of liquid at him. A number of officers attacked Dennis in his cell. Emergency Room records indicate that Dennis suffered blunt trauma to his head and body, three teeth knocked loose, and a laceration to his lower lip from this incident.
3. In April 2007, Billy D. wanted to exit his cell and was accused of pushing his way out. He had a nheated" verbal altercation with the officer. One officer struck Billy in the face and other officers joined in. Medical records show that Billy required internal and external stitches to close a one-inch laceration that punctured his lip.
4. In September 2006, an officer was handing out extra lunches to inmates. Malcolm W. asked for one, but was refused. Malcolm and the officer exchanged verbal insults. A mental health staff member and another inmate witnessed the officer slap Malcolm's face and drag him from the dorm. CCJ's Internal Affairs Division (nIAD") sustained allegations of abuse, and recommended that the officer be suspended for 29 days. The officer was ndedeputized" and prohibited from carrying a firearm or effecting arrests.

6

To protect privacy, we have used pseudonYms to identify

inmates and officers listed in this letter. Upon request, we

will provide the County with a schedule that cross-references the

pseudonYms with the proper names, where appropriate.

I·
- 12 -
5. In March 2006, Danny P., who according to CCJ records was a slight man of 5'1" and 110 pounds, was on his way to the law library. He got into a shouting match with the female officer escorting him, which resulted in him being taken back to his housing unit. Near the secure staff station, the officer lunged at Danny and began to slap him. Two other officers grabbed his arms and pushed him into a dayroom. As he was being handcuffed, several other officers continued to punch and kick him. He was hit in the mouth after being handcuffed. CCJ records show that a sergeant found Danny standing outside the security office handcuffed and bleeding about the face. The female officer was disc~plined for failing to report the incident in a timely manner and also for failing to obtain medical treatment for Danny. Danny filed a lawsuit against CCJ regarding this incident, and the parties agreed to settle the case in March 2008.
b. Use of Force for Failure to Follow Instructions
It is inappropriate and excessive to use force for rule violations which do not present a threat to safety or security. At CCJ, inmates' failure to follow orders too often lead to physical abuse, even where no security risk is present:
1. In June 2007, there was a fight on Thomas K.'s unit, in which he did not participate. A group of officers came to the unit, strip-searched the inmates, and sent them back to their cells. As Thomas started to go up the stairs to his top tier cell, his hands were on his neck holding his shirt, instead of on top of his head, as he had been directed. An officer grabbed Thomas by the neck, which choked him, and Thomas reacted by grabbing the officer's arm. The officer immediately swung and hit Thomas in the eye with a walkie-talkie, causing a wound that required five stit@hes to close. Cermak medical records confirm Thomas's injuries and that he was hit with an ~unknown object." The officer continued hitting Thomas after the first blow, although Thomas offered no resistance. We observed Thomas's injuries during our on-site visit.
2. In February 2007, Matthew S. was ordered to leave the barber shop for standing up before his turn. When he tried to explain why he stood up, an officer grabbed him by the collar and told him to leave the barber shop. Matthew argued with the officer. Outside the

- 13 -
barber shop, officers shoved his head into the concrete after he had been handcuffed. CCJ records confirmed that Matthew needed· stitches to his face and a tetanus shot following this incident, but he refused treatment.
3. In April 2006, Terrence M. was being processed in his division when an officer noticed that Terrence had an unauthorized shirt. The officer asked for the shirt, but Terrence refused to give it to him. After Terrence was restrained, the officers punched and kicked him. As a result of the beating, Terrence suffered a broken jaw that required surgery at an outside hospital. CCJ found abuse by one officer, and. the officer was terminated.
4. In April 2006, Darnell J. refused to go to recreation when he was told he could not first use the bathroom. Several officers shoved Darnell into the hallway where they beat and kicked him. A sergeant watched and then joined in the beating. Two other inmates in the hallway were also beaten. Darnell was hospitalized for neck injuries. CCJ found abuse by the sergeant and seven officers and also that the sergeant and several officers had filed false reports. lAD recommended termination for the sergeant and three officers.
5. In March 2006, John S. was being strip-searched prior to going to recreation. He was tapping on the wall. An officer ordered him to stop and hit him on top of the head. John continued to tap. After John was searched, the officer said: "You're f------ guilty" and slammed him on top of a cart and against the wall. John was pulled into the hallway where other officers started to beat him. He was hit in the face, dragged by his hair, choked, and beaten. Photographs of John in the CCJ files show injuries to his face and body. lAD found that the officers used excessive force and recommended that two officers be terminated.
6. In March 2006, Jacob D. objected to a tier change and insisted on speaking with an officer. Three officers extracted him from his cell. He was handcuffed behind his back and, while they were taking him to the segregation.unit, the officers pushed his head into the wall. He was hit in the face, thrown down stairs, kicked, and punched repeatedly. Photographs of Jacob from the following day show that his face was badly bruised and his eye was swollen shut. lAD found that

- 14 -
three officers used excessive force and recommended that they be suspended for 29 days.
7. In January 2006, Byron S. was cleaning the dayroom with other inmate workers when a group of officers accused Byron and another inmate of planting contraband in the visiting area, and took both inmates into the hallway. Byron was beaten by multiple officers. After he was handcuffed and lying on the floor, Byron received a blow that broke his jaw. Medical records confirm that his jaw was fractured. Byron's jaw was wired shut at an outside hospital, which required him to eat with a strCiw. Three rnonths 1 c3,t e:f , BY:fcm req1.lirE!d. acidi t:L()na:L surgery and his jaw was wired shut for a second time. Byron filed a lawsuit against CCJ regarding this incident, and the parties agreed to settle the case in September 2007.
8. In January 2006, Michael A. was resisting going to disciplinary segregation because he believed he had already served his time for the infraction in question. He asked to talk to a sergeant, who said that nothing could be done. When he continued to resist, stating that he wanted to talk to a captain, a correctional officer said: "No," and struck him in the face. Other officers were called and joined in beating him. He was sent by ambulance to an outside hospital. Medical records show he suffered a fractured nose and two black eyes.
c. Use of Force as Punishment or Retribution
We found that inappropriate and excessive use of force also occurs when officers are angry and upset about inmate violence against staff. Physical force ·is also sometimes inappropriately used at CCJ even after an active dispute between an inmate and officer has.ended, apparently to punish the inmate .. Retaliatory force even occurs when officers are dealing with mentally ill inmates with limited impulse control, although the inmates do not present a threat to themselves or others. 7 The use of ,force is

7

According to a division superintendent, a number of

officers assigned to the tiers for inmates with mental illness

have not received training on working with the mentally ill. The

excessive use of force with mentally ill inmates is likely

attributable to lack of, or ineffective, officer training.

- 15 -
never appropriate as retribution for previous bad acts and is inappropriate when an inmate is not a present threat:
1. In July 2007, Robert T., who suffers from mental illness, exposed himself to a female officer. In response, he was taken to a clothing room where a group of officers handcuffed him and then proceeded to hit and kick him after he was restrained. CCJ records confirm that Robert was sent to an outside hospital with severe head trauma.
2. In June 2007, Russell G.'s cellmate opened the cell door and Russell got out of his cell. In response, an officer locked all the inmates in their cells. After Russell was back in his cell, officers sent his cellmate downstairs and entered Russell's cell. The officers handcuffed Russell, then stomped on his back and hit him. His eye became swollen and his teeth were chipped. Before taking him to the dispensary, the officers threatened to beat Russell again and charge him with battery unless he told medical staff that he had hurt himself falling off his bunk. Russell was sent from the dispensary to Cermak Hospital for medical treatment.
3. In August 2006, an inmate stabbed an officer. Because Martin S. had argued with the officer earlier in the day, officers erroneously believed he had committed the stabbing. 8 As a result, officers responded to an "all available" call and began to "beat Martin in the mistaken belief that he was the inmate who had assaulted the officer. Besides being punched and stomped, he was also hit with a radio and kicked in the groin.
4. Inmate Andrew B. was also housed in the unit where the August 2006 attack on the officer occurred. Andrew had nothing to do with the attack. A large number of officers came onto the unit and proceeded to beat the inmates indiscriminately. Andrew was ordered to lie down and, while he promptly obeyed, he was stomped and kicked by the officers.

8

CCJ records confirm that another inmate was charged

with the crime.

- 16 -

5. In April 2006, Damien H. pushed out of his cell. An officer escorted him back to his cell. At the door of his cell, Damien turned and hit the officer, for which he was charged with aggravated battery. All available officers were called and, while restraining Damien, several officers punched, kicked, and stomped him. lAD found that three officers had used excessive force and recommended 29-day suspensions for all of them.

6. In January 2006, an officer wanted Jerry M. to return

to his cell, which Jerry resisted, and the officer

rolled the door over Jerry's foot. Jerry called the

off:Lc::er a "}:)

.tl _The o:f:ficerthen beat Jerry with'

handcuffs wrapped around his hand like brass knuckles.

A CCJ internal investigation of this incident found ,

that excessive force had been used and recommended that

the officer be terminated. The Sheriff's Merit Board,

which hears CCJ termination cases, ruled against CCJ

and reinstated the officer to duty.

d. Use of Force at Intake

The pattern of inappropriate and excessive use of force is distributed throughout the CCJ divisions, and not confined to the areas where the use of force is most likely to occur in a correctional setting: the maximum security units and intake area. However, an especially high number of abuse of force allegations do emerge from CCJ's RCDC intake unit.

There is unanimity of opinion among those familiar with CCJ, including administrators and staff, the County, the Sheriff's Office, and the court monitors, that conditions in RCDC are unacceptable and must be changed. As discussed in more detail below, the RCDC is chronically overcrowded, cramped, chaotic, and insufficiently staffed. The impact of these conditions on the use of force is considerable. In the RCDC, inmates who request attention for various needs run the risk of becoming victims of physical abuse. Inmates are especially vulnerable to abuse when they are taken in large groups to be strip searched in an isolated area out of the view of non-security intake staff. Many inmates report that those who are old, mentally ill, or do not understand English, are struck by officers for undressing or dressing too slowly. Finally, inmates may also be targeted for physical abuse because of the charges for which they were arrested.

1. In September 2006, Pedro S. was arrested on a sex charge brought by his niece. While in the intake area,

- 17 -
three officers who had read his charge began taunting himr yelling threats in Spanish r and asking if he knew what was about to happen to him. The officers struck him many times and called him'a "f------ Mexican." The other inmates were ordered to turn and face the wall "or else." Because the officers threatened to kill Pedro if he said anything about the incident r he did not.seek medical attention. Pedro was released four days later and immediately saw a doctor and reported the incident to the Chicago Police Department. The Police Department contacted CCJ. Medical records confirm that Pedrors injuries included a broken rib and damCige to his jaw and knee.
2. In July 2006 r Lonnie L. r 59-years-old r was leaving the medical area of intake and heading to the bullpen. When he turned around to get more medication r an officer told him not to return to the medical area. Lonnie did not obey the order. The officer came into the medical area and hit Lonnie on the mouth. When Lonnie fell to the ground r the officer kicked him and again struck him in the mouth r knocking out a tooth. The officer dragged Lonnie by the pants out of the medical area. During Lonniers intake strip search r the same officer hit him in the back with a cane. Three inmates testified that they witnessed the incident. Medical records indicated injury to Lonniers ribs and lung. CCJ found abuse and recommended that the officer be terminated.
3. While being processed into CCJ in May 2006 r Antonio R. was wandering around the intake area asking for his methadone. An officer told him to return to his holding pen. Antonio apparently did not obey quickly enough r as the original officer and others proceeded to beat himr first in the main open area and then in an adjoining tunnel. They hit Antonio with a radio r knocked out his dentures and smashed them under a boot. As a result of this incident r Antonio suffered multiple fractures and a collapsed lung. After being returned from one outside hospital r he was sent to another in acute respiratory distress. He was transferred to a Levell trauma center r where he needed to be placed on a ventilator. Medical records confirm Antoniors severe injuries.
4. In February 2006 r while being processed into the CCJ for driving on a suspended licenser James W. would not

- 18 -
(and could not) remove jewelry embedded in a piercing because it was permanently soldered. The officer conducting the strip search attempted to strike James, who blocked the blow. The officer then called over other officers, who hit James in the face multiple times. One officer hit him repeatedly with a handcuff wrapped around his hand. James later stated that the officers had used his head as a Ubongo drum." Medical records confirm that James was diagnosed with a perforated ear drum and blood in his right ear at Cermak Hospital the next day. Additional records show that the incident resulted in diminished hearing in one of James's ears. James filed a lawsuit against CCJ concerning this incident and the parties agreed to settle the case in March 2008.
e. Inadequate Oversight of Use of Force
'Effective measures to prevent excessive and inappropriate uses of force start with the adequate reporting of information to permit the identification of potential problem cases and effective internal investigations. We find that CCJ fails to elicit adequate information about use of force incidents, making management review ineffective. We also find that, in most cases, internal affairs investigations of use of force are undertaken only when a lawsuit is filed, rather than when a serious incident occurs.
i. Management Review
In order for CCJ to provide adequate oversight of officers' use of force, management must have adequate information to review incidents and reach a conclusion as to the propriety of a use of force. While all officers involved in a use of force incident fill out a Use of Force Report, in most cases these reports provide very little information because they are written in generalities. For example, numerous Use of Force reports fail to describe, in factual terms, the type and amount of force that officers used. Many Use of Force Reports merely describe the force used with phrases such as, uused the least amount of force necessary to gain control of the inmate" or ufaced inmate to the floor." Although most shift commanders review Use of Force and Incident Reports to ensure that reports are completed, some commanders reported that they do not review the reports' for substantive content. Although copies of Incident Reports are forwarded to CCJ's Executive Director, Assistant Executive Directors, Superintendents, and the official file, it is unclear

- 19 -
if the administration routinely conducts any additional review of these reports.
Moreover, while in most cases there are both Incident Reports and Use of Force Reports, the reports generally do not indicate the nature or extent of an inmate's injuries, arguably the most telling indication that there may have been an inappropriate use of force. The reports usually conclude with an inmate being taken for ~medical attention," but with no indication of why medical attention was required. The reports also fail to capture the time the inmate received medical attention, which makes it difficult to assess whether medical attention was promptly provided. In_the May 2006 case of Jacob D., there is no indication of any injury in the CCJ reports, but when Jacob was transferred the next·day to the Illinois Department of Corrections (~IDOC"), his facial bruising and swelling was so severe that the IDOC contacted CCJ immediately to report the physical condition of the incoming prisoner. In the case of John S., there is also no indication of injury in the CCJ reports about a March 2006 incident. The reports simply state that John was taken for medical attention and released from the dispensary, with no mention of any injuries. In fact, as photos taken later show, John suffered two black eyes and a swollen lip, among other injuries. In both of these cases, CCJ eventually found excessive use of force by the officers, but the reports themselves were devoid of helpful information. 9
Because the information contained in Use of Force and Incident Reports is insufficient for management to determine whether the incident raises suspicions concerning use of force, review by management, when it occurs, usually does not result in identifying cases for investigation. There can be no effective oversight if necessary information is not put forth when the incident happens. For example, a report indicating that an inmate sustained a black eye after an inmate-officer altercation should raise concern, but management will never know about the black eye under the current system.
In addition to the lack of information contained in CCJ reports, we discovered that the Incident Reports did not contain a tracking number or source of issuance until a July 2007 initiative by the Executive Director. This initiative is consistent with generally accepted correctional practice. Previously, it was extremely cumbersome to track anyone incident

9

In both of these cases, investigations were initiated

as a result of external complaints.

- 20 -
(for use of force and other serious incidents) and, in all likelihood, impossible to ascertain if all incidents were being report~d and processed. Incident tracking numbers are now to be issued by External Operations staff. Serious incidents and uses of force should also be tracked by each division with a uniform logging system for recording serious incidents at all levels of CCJ.
Finally, CCJ has no tracking or early warning system to identify those officers who are the most frequent users of physical force and those whose actions have elicited the most complaints of excessive force, grievances, or injuries. An appropri0te early warning system is an accountability tool that allows for early intervention by alerting a facility to a need for retraining, problematic policies, supervision lapses, or possible bad actors. In 2004, CCJ hired an external consulting firm to review it~ policies and procedures regarding the use of force after a special grand jury concluded that a 1999 incident, in which correctional officers beat and terrorized 49 inmates at CCJ, constituted ugross, if not criminal, misconduct." The consulting report recommended that CCJ institute an early warning system Uas soon as possible." The 2004 recommendation was never implemented.
ii. Investigations
To ensure reasonably safe conditions for inmates, correctional facilities must develop and maintain adequate systems to investigate staff misconduct, including alleged physical abuse by staff. Beyond management review, the avenue for oversight at CCJ is the Internal Affairs Division (UIAD"). Generally accepted correctional practices require clear and comprehensive policies and practices governing the investigation of staff use of force and misconduct. Adequate policies and practices include, at a minimum, screening of all Use of Force and Incident Reports, specific criteria for initiating investigations based upon the report screening, specific criteria for initiating investigations based upon allegations from any source, timelines for the completion of internal investigations, and an organized structure and format for recording and maintaining information in the investigatory file. The investigation must also be and appear to be unbiased. CCJ's investigatory practice fails on multiple levels .
. To be effective, investigations must be undertaken promptly. A jail, by its nature, has a tremendously high turnover of inmates. An inmate whose incident is being investigated may well have left CCJ if the investigation does not occur soon after the

- 21 -
incident, and the same is true for inmate witnesses. Because CCJ does not initiate many use of force investigations, most use of force investigations are not opened until long after an incident has taken place. Instead, investigations are undertaken because the inmate has filed a lawsuit, which can be up to two years after an incident occurs. For example, the investigation of Michael A.'s January 2006 beating did not begin until 16 months after the incident, despite the fact that Michael was treated at an outside hospital, suffered a fractured nose, and had, according to the medical records, ~raccoon eyes." The investigation of the incident in which Byron S. suffered a broken jaw did not start until Byron filed suit seven months later, even though Byron's visible injuries required him to eat through a straw with his jaw wired shut. Because of the delay, inmate witnesses to the occurrence will likely have left CCJ by the time an investigation begins. lAD's only attempt to reach an inmate witness who has ~eft CCJ is a form letter to a last known address, which rarely elicits any response. We found that many investigations are simply und~rtaken far too late to be effective.
Perhaps even more troubling is the fact that investigations are reactive and suffer from the appearance of bias. The vast majority of lAD files we reviewed stated that the investigation of use of force was opened at the request of CCJ's attorney in response to an inmate lawsuit CCJ is defending in court. It is almost impossible for lAD to appear fair and unbiased when the investigation is undertaken only because CCJ is defending an inmate lawsuit. All uses of force should be appropriately reviewed through the chain of command. Whenever Incident Reports, Use of Force Reports or other information raise the possibility that excessive force was used, such incidents should be thoroughly investigated by lAD. In particular, incidents involving suspicious inmate injuries, such as black eyes or blunt head trauma, and incidents requiring medical care at an outside hospital should be investigated by lAD. An appropriate evaluation of incidents for investigation will require more detailed Use of Force and Incident Reports and a more thorough management review than CCJ's current practice.
lAD also reported a backlog in resolving use of force cases and incidents involving inmate-on-inmate assaults because it is difficult to obtain medical releases from Cermak, CCJ's on-site health care provider, in a timely manner. 10 Obtaining medical
10 lAD is under the Sheriff's Office while Cermak is part of the Cook County Bureau of Health.

- 22 -
records from Cermak can take anywhere from six to 12 months, which prevents lAD from bringing prompt closure to an investigation. This type of delay is totally unacceptable, and is devastating for any investigation.
We also found that there are attempts by officers or other staff to conceal the inappropriate or excessive use of force. CCJ officials found that the officer involved in the January 2006 beating of Jerry M. had attempted to persuade a sergeant on the .tier to change his story as to what had happened. In another case, Russell G. reported that the officer who caused his injuries in June 2007 threatened him with worse treatment unless he told the medical staff that he had hurt himself by falling out of his bunk. We found two accounts of senior division staff attempting to dissuade inmates from complaining about the use of force, in one case by/the offer of a favor and in the other by the threat of criminal charges. CCJ's administration and lAD must take action to ensure that inmates are not intimidated into concealing excessive use of force and that information received is accurate and credible.
Finally, we also found flawed investigatory techniques at CCJ. For example, investigators often do not give sufficient attention to the inmate injuries that are known. When investigators question officers accused of using excessive force, the officers are generally not even questioned as to how an inmate's particular injury might have occurred. For example, lAD opened an investigation of the March 2006 case of Antonio R. after a doctor at an outside hospital reported that Antonio was in serious condition with ~blunt trauma all over his body." Although the investigator was aware of Antonio's injuries at the time he questioned both of the officers involved, he never asked the officers about the nature of Antonio's injuries or how they occurred. While there may sometimes be tactical reasons to avoid discussing inmate injuries when an officer is first questioned, the investigation is incomplete if the officers are never asked to address the inmate's resulting injuries.
We found other examples of investigatory techniques that are unlikely to result in complete or credible information. For example, on March 9, 2006, an investigator interviewed inmate Gabriel M. about a use of force incident involving another inmate in his tier. The investigator then attempted to interview Gabriel's cellmate about the same incident but, since the cellmate could not speak English, the investigator utilized Gabriel as the Spanish interpreter to provide his cellmate's statement. Relying on one inmate to translate for another inmate in an investigation involving both of them is a poor

- 23 -
investigatory technique that calls into question the credibility of the information gathered by CCJ investigators. 11
iii. Videocameras and Overhead Cameras
When properly utilized, cameras in a correctional setting can augment inmate safety and security and provide essential information for investigations. Certainly video surveillance should never be used to substitute for direct officer supervision of inmates, but it often is helpful to supplement supervision and for incident reconstruction. CCJ has limited and antiquated live feed overhead cameras in some divisions, but the cameras do not have . the critical capability to . record. and replay, and most do not capture activities outside of the housing unit dayrooms. Moreover, while there are two small monitors in the RCDC intake area, we discovered that the officers in the Security Office were unaware that the monitors could view various parts of the intake area. The cameras, installed to monitor activity in a part of CCJ that had experienced among the highest number of allegations of excessive and inappropriate uses of force, were not being used.
Procedures at CCJ require that a handheld videocamera be brought to the scene of any use of force and that the use of force be recorded. While this policy is helpful for review of cell extractions and other planned uses of force, it is not surprising that the use of handheld videocameras has not been an effective means of oversight for unplanned uses of force. None of the numerous videotapes we reviewed captured an unplanned use of force in progress. Improvements and additions to CCJ's video surveillance system, including the ability to record for retrieval following an incident, would be a much more effective oversight mechanism.
2. Deficient Inmate Safety and Supervision
CCJ does not provide adequate inmate supervision, which exposes inmates and staff to unsafe conditions. Lack of adequate
11 Title VI of the Civil Rights Acts requires that recipients of federal funds take reasonable steps to provide meaningful access to limited English proficient communities. Given Cook County's growing Hispanic population, CCJ should ensure that some investigators and correctional officers are familiar with rudimentary Spanish. In addition, CCJ staff would benefit from receiving diversity training. See Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d et ~

- 24 -
security staff, insufficient direct supervision in the majority of the housing units, a dilapidated physical plant, inadequate policies and procedures, and an overcrowded environment combine to result in an unsecure facility that is dangerous for everyone on the premises. On April 9, 2007, the John Howard Association found that the rates of injuries to CCJ inmates and staff have increased significantly in the past decade, despite a substantial decrease in inmate population. 12 In 2006, inmate injuries occurred at the highest rate since the John Howard Association began gathering data, and staff injuries reached the third highest rate since 1991. 13 Our review of CCJ documents revealed that between January 1, 2007 and June 19, 2007, lAD opened approximately 254 cases involving inmate assault and/or battery and five cases of sexual assault. In 2006, lAD opened approximately 357 cases involving inmate assault, battery, or sexual assault.
Insufficient inmate supervision has been a serious problem at CCJ for decades. Inmate supervision is seriously compromised by chronic overcrowding and under-staffing. The federal district court monitoring the Duran Consent Decree has repeatedly cited CCJ for failing to provide adequate security staff to ensure safe and secure conditions at the facility.14 In September 2006, then-Sheriff Michael Sheahan admitted that the Jail is ~severely understaffed. "IS The John Howard Association's April 9, 2007 report found that CCJ would require an additional 189 new correctional officers and suitable replacements for the 130 to

12 Court Monitoring Report, Duran v. Dart, No. 74-C-2949, at 115-16 (N.D. Ill. Apr. 9, 2007) (~2007 Court Monitoring Report"). Monthly averages for staff injuries have risen from 6.6 in 1996 to 28.3 staff injuries per month in 2006.

13 Id. at .116. Monthly averages for inmate injuries increased·from 14.7 injuries per 1000 inmates in 1996 to 27.8 injuries per 1000 inmates1 in 2006.

14

Leonard N. Fleming, ~Federal Judge Warns County to Fix

Overcrowding at the Jail," Chicago Sun Times, Dec. 1, 2007i

Jonathan Lipman, ~Judge Blasts Staffing at Jail," Daily

Southtown, Dec. 29, 2005.

IS Joint Status Report, Duran v. Dart, No. 74-C-2949, at 8 (N.D. Ill. Sept. 29, 2006).

- 25 -
152 correctional officers on inactive status16 to comply with the Duran Consent Decree and "good correctional practices."17 CCJ's Post Analysis Reports and Divisional Staffing Reports for April through June 2007 revealed that at least 172 correctional officer positions at CCJ were vacant or inactive. Although the External Operations Unit, which is responsible for the security of the CCJ perimeters, the Emergency Response Team, the Canine Unit, and the transportation of 800 to 1500 inmates to and from court daily, has an authorized security staffing complement of 420 positions, on May 1, 2007, the actuai External Operations manpower availability comprised 352 positions. Our expert consultant found that the level of correctional staff available to supervise housing units at CCJ is woefully inadequate.
The lack of adequate staff is magnified by the fact that CCJ is chronically overcrowded. In fact, every day from June 2006 through April 2007, num~rous inmates were required to sleep on the floor of two-person cells that house~ three inmates. 18 Divisional reports for the period of February 26, 2007 through June 17, 2007 reflect that an average of 485 inmates were forced to sleep on the floor each night. During our site visit on July 23, 2007, Division VI held 1268 inmates in space with a rated capacity of 992 inmates. 19 Dormitory Four in Division II is operating at twice its design capacity.20 However, we did not observe any increase in security staffing levels or enhanced supervision practices within the overcrowded divisions.
Overcrowding has an impact on security at CCJ. For example, the week of March 19, 2007, CCJ had more inmates sleeping on the floor (591) than any other week in the four-month period of March through June 2007. During that week, CCJ also had the most fights (35), the most uses of force (27), and found the third most "shanks" (homemade knives) (34) and second most weapons

16 Correctional officers on "inactive status" include persons on disability, suspension, leave of absence, military leave, or leave for a duty injury.

17

2007 Court Monitoring Report at 84.

18

Id. at 12.

19 The actual capacity of Division VI was much lower than 992 on July 23,.2007, due to numerous cell closures because of maintenance problems r which further exacerbated the overcrowding.

20

2007 Court Monitoring Report at 15.

- 26 -
(12), of any other week during the same period. 21 On November 30, 2007, Judge Virginia Kendall for the United States District Court for the Northern District of Illinois apparently chastised the County and Sheriff's Office for failing to ease overcrowding at CCJ, stating: ~This is no longer a budget problem. It is a constitutional violation."22 Despite the fact that CCJ has been subject to the Duran Consent Decree for 25 years, the County and the Sheriff's Office have been unable to solve the problems of overcrowding and inadequate supervision at CCJ.
CCJ has taken some unusual steps to try to deal with the problems of overcrowding and inadequate staffing. The practice of cross watching, discussed below, is an unacceptable and dangerous approach. A recently instituted policy of extended lockdowns is similarly unacceptable. In the spring of 2007, CCJ implemented extended lockdown periods for all general population inmates. Under this system, only half of the inmates in each housing tier were allowed out of their cells during each shift. Generally, this meant that half of the inmates were allowed out· of their cells for a period in the morning, half of the inmates were allowed out of their cells for a period in the afternoon and evening, and all of the inmates were locked in their cells during the night. Because the groups of inmates rotated on a shift by shift basis, the result was that every other day each group of inmates spent a continuous 26-hour period locked inside the cells. This practice was applied indiscriminately to all general population inmates, except those housed on the medical units. As discussed in further detail below, in addition to constituting an unjust restriction on pre-trial detainees, the extended lockdown practice interfered with medical and mental health care, programs, and .the grievance system. Moreover, deficient maintenance in many cells (no lighting, plumbing failures, etc.) resulted in inhumane conditions for an extended lockdown. Therefore, as a result of CCJ's inadequate supervision, inmates are subjected to unjustified, prolonged periods of in-cell confinement. Following our July 2007 visit, the Sheriff's Office informed us that CCJ had revised the lockdown policy to decrease the length of the in-cell periods. This would be an improvement

21 Weekly averages for March through June 2007 were: 23.5 fights, 17 uses of force, 23.5 shanks, and 6.6 weapons.

22

Staff Writer, ~Judge Orders Cook County to Fix Jail

Overcrowding," PR Newswire Europe, Nov. 30. 2007j Leonard N.

Fleming, ~Federal Judge Warns County to Fix Overcrowding at the

Jail," Chicago Sun Times, Dec. 1, 2007j Notification of Docket

Entry, Duran v. Dart, No. 74-C-2949 (N.D. Ill. Nov. 30, 2007).

- 27 -
and a welcome change, and we look forward to assessing the new lockdown system. 23
As discussed below, the result of CCJ's inadequate inmate supervision is that inmates and staff are exposed to unsafe conditions, an increased risk of violence and an abundance of dangerous and illegal contraband.
a. Assaults on Inmates and Staff
The severity and frequency of inmate-on-inmate assaults demonstrate that CCJ is not providing for the safety and well-being of the inmates. In a period of less than two months in the spring of 2006, inmates reportedly engaged in at least seven separate knife fights that resulted in serious injuries to at least 33 inmates and seven correctional officers, including one inmate death. 24
Weekly Divisional Reports from February 26, 2007 through June 17, 2007 show an average of 23.5 inmate fights and 3 incidents of ~battery to staff with injury" per week at CCJ. Many of these incidents occurred in CCJ's maximum security divisions, where inmates should be supervised at the highest level, and extra precautions should be taken to minimize access to, and creation of, shanks and other weapons. Clearly CCJ cannot be expected to prevent all altercations between inmates. Nevertheless, the Constitution requires correctional officers and Cook County officials to take ~reasonable steps to protect

23 CCJ's latest attempt to deal with overcrowding involves a ~hot bunking" pilot program whereby inmates volunteer to take turns using the same bed in eight-hour shifts. See Sheriff's Supplemental Report, Duran v. Dart, No. 74-C-2949, at 2 (N.D. Ill. Jan. 15, 2008). Although each inmate is reportedly using his or her own bedding, the hot bunking procedure could result in serious sanitation and infection control problems, as well as possible inmate-to-inmate intimidation regarding potential volunteers.

24

See e.g., William Lee, ~Two Cook County Jail Inmates

Were Stabbed During a Fracas in a Maximum-security Division

Monday Night," Daily Southtown, May 2, 2006; Lori Rackl, ~2

Inmates in Hospital After Jail Brawl," Chicago-Sun Times, Apr.

24, 2006; William Lee, ~Seven Inmates at Division 11 are Injured

by Homemade Knives in a Gang-Related Fight," Daily Southtown,

Apr. 24, 2006; Staff Writer, ~Knife Fights in Cook County Jail

Injure 17," Chicago Tribune, Mar. 13, 2006.

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inmates from violence at the hands of other inmates." Goka v. Bobbitt, 862 F.2d 646, 649-50 (7th Cir. 1988). The level of inmate-an-inmate and inmate-on-staff violence that is occurring within CCJ is so unacceptably high that it is clear that inmates are not adequately supervised, in accordance with generally accepted correctional standards. Notably, just as the Court and CCJ staff have recognized the shortage of staff supervision, inmates are also aware that they could engage in violence with little to no supervision. Much of the violence at CCJ involves group attacks, which reflect some degree of planning and coordination by the inmates, without the staff's knowledge or intervention.
As the fOllowing. examples demonstrate, CCJ is not meeting
its constitutional obligations to provide for the safety and well-being of its inmates:
1. On December 29, 2007/ multiple inmates suffered stab wounds during a fight in a Division IX dayroom. Six inmates require<d treatment from outside hospitals and two inmates were admitted to the hospital with multiple stab wounds and other serious injuries. Officers were required to use Oleoresin Capsicum spray ("OC spray") to break up the fight. CCJ recovered four shanks/ some of which measured six inches in length/ and another weapon in the tier. Despite the severity of this incident/ lAD did not open an investigation file.
2. On June 26, 2007/ an officer delivering breakfast trays found inmate Louis J. unconscious on the floor of his cell in Division IX. Louis J. was admitted to the hospital for trauma and died on July 8, 2007/ as a result of his injuries. Hospital records showed a hematoma with fractures and wounds to the face and head. Although the Incident Report related to this incident states that Louis J. may have suffered a seizure/ Louis J./s cellmate was promptly transferred to CCJ/s highest level of disciplinary segregation/ the Level IV Special Incarceration Unit in Division IX. However/ CCJ could not produce a disciplinary citation/ hearing record/ or investigation documentation on the incident. 25 Louis J./s cellmate was still in the
25 We requested all documentation related to this incident on multiple occasions. We never received any disciplinary or investigation records. CCJ did not complete a mortality review for Louis J./ allegedly because he was no longer in custody at the time of his death.

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Special Incarceration Unit a month after the incident, during our July 2007 site visit.
3. On June 26, 2007, officers noticed that several inmates from Tier 4B were running as they returned from the Division X gymnasium. Officers found several inmates with stab wounds and other injuries in the corner of the gymnasium. One inmate was hospitalized with a stab wound to the neck and another inmate had a broken jaw. The fight was apparently the result of different gang affiliations mixed within the tier. Upon investigating, officers recovered three shanks. CCJ placed the entire 48-inmate tier on extended lockdQwn from June 26 through July 8, 2007, whereineachin!l1ate was allowed out of his cell for only one hour per day, and only one inmate was allowed out at a time. No other obvious precautions were taken to address the gang problem on the tier. When the lockdown ended on July 8, another fight broke out involving some of the same inmates and the same gangs as the June 26 incident. One inmate was stabbed and officers recovered another shank.
4. On June 20, 2007, inmates Auben J. and Sam D. suffered injuries to their heads and faces following a fight in the outdoor area of Tier A-H in Divisiorr~IX. Because no officers witnessed or responded to stop the fight, it was eventually broken up by another inmate, Roger R. Officers only learned of the fight after observing Auben J. bleeding from the head when he returned from exercise. Because Roger R. admitted that he helped separate the fighting inmates and injured Auben J. in doing so, he was transferred to disciplinary segregation along with Auben J. and Sam D.
5. On May 10, 2007, seven inmates were treated for stab wounds after a gang-related fight involving approximately 25 ,inmates in the Division IX, Tier 3C, dayroom. Inmates Mark V., Alex W., and Arthur A. had to be transferred to outside hospitals for medical treatment. CCJ staff found a shank in the dayroom.
6. On December 5, 2006, 31-year-old Marcus K. was found dead in his cell. His cellmate was charged with first-degree murder for allegedly strangling Marcus K. after the two were heard arguing. The two men were locked in their cell at the time, and other inmates in

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the common area alerted a correctional officer that an inmate needed help during the altercation.
7. On April 22 1 2006 1 inmate Izzy J. suffered a fatal stab wound to the head during a gang-related fight involving approximately 20 inmates in Division XI. Six other inmates were hospitalized after the brawl; five of the inmates were stabbed with shanks.
8. On April 2 1 2006 1 inmates Tyson D. and Freddy R. were seriously injured during a gang-related fight involving at least six other inmates in Division XI. Both Tyson D. and Freddy R. were admitted to the hospital with multiple stab wounds to the back.
In addition to the inmate-on-inmate violence l CCJ/s security failings put staff in danger as well:
1. On March 22 1 2007 1 maximum security inmate Reed W. stabbed a correctional officer I a nurse I a hospital patient l and a bus driver during an unsuccessful escape attempt at Stroger Hospital l where he had been taken for a doctorls appointment. CCJ officials reported that Reed W. may have smuggled a shank out of CCJ Division IX in his rectum.
2. On August 16 1 2006 1 correctional officer Ben W. was hospitalized for five days and required 30 stitches after being attacked by inmate Daniel M. in Division V. The inmate was able to run from the scene before any other officers could come to O~ficer W./s aid.
3. On April 15 1 2006 1 six officers received medical treatment I and at least four inmates were hospitalized for stab wounds I after a multiple-inmate fight broke out in a Division XI dayroom. Officers recovered several wooden sticks and at least one metal shank following the fight.
b. Inadequate Security Staffing
As a result of insufficient security staffing l CCJ is not providing adequate supervision of the inmate housing areas. As discussed above I a major concern surrounding inmate supervision is the practice of "cross watching." Cross watching refers to the practice of having one correctional officer simultaneously

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supervise two tiers of cells as opposed to one. 26 The correctional officer monitors the second tier on camera while stationed in the first tier's control center. By policy, the officer supervising a housing unit is supposed to conduct security rounds inside the unit every 30 minutes, which allows him to check on inmates in their cells and in the shower and bathroom areas. These areas are not visible on the security monitors or from the officer's standard post inside unit's control center. However, if or when the officer conducts a security check inside the first housing unit, the second housing unit is unsupervised. If the officer leaves the control center of the first housing unit to conduct a check of the second housing unit, the inmates in the first housing unit can see that there is no officer supervising their actions. 27 Although we recognize that CCJ has made efforts to increase staffing levels in housing units and decrease cross watching, we observed numerous instances of cross watching during our June and July 2007 visits to CCJ. The practice is highly utilized during lunch periods, but we also observed cross watching throughout the day.
As noted earlier, because inmates are aware when there is not an officer in the housing unit, there is a higher risk for illicit inmate behavior, including inmate assaults, production of weapons, and gang and drug activity. For example:
1. On May 15, 2007, an officer was cross watching two tiers in Division IX, a maximum security division. Inmate Carson T. was assaulted by five or six inmates in the tier dayroom. He received multiple wounds to his shoulders, back, face, and was admitted to the hospital. The cross watching officer did not notice anything amiss until he saw inmate Carson T. pacing by the tier door. CCJ documents noted that Carson T. had "injuries resulting from being attacked with a homemade knife" and that a "small piece of metal was sticking out [his] back." During the subsequent investigation, security staff found two shanks in the tier; No officer observed the dayroom assault.
26 Cross watching is prohibited by the Duran Consent Decree and the John Howard Association has cited CCJ for the practice, but it continues to occur. See 2007 Court Monitoring Report at 86.
27 The number of inmates per housing unit varies across divisions, but it is not unusual for one cross watching officer to be responsible for more than 90 inmates in two units.

- 32 -
2. On May 10, 2007, also in Division IX, an officer was cross watching two tiers when a disturbance involving 25 inmates occurred. Seven inmates received injuries including multiple lacerations and puncture wounds.
3. On December 24, 2006, the assigned officer was cross watching two tiers in Division VI when inmate George W. assaulted inmate Otis F., causing a head injury.
4. On July 25, 2006, inmate Andrew K. committed suicide in Division I while the assigned officer was cross watching two tiers. The Medical Examiner reported that, inmates discovered Andrew hanging by the cell bars r alerted officers r untied his noose r and initiated chest compressions before staff intervened. Although staff reported that sight checks occurred in the tiers on a frequent basis r it is not clear if the officer actually saw Andrew in his cell at the times reported. InexplicablYr the CCJ investigation of the incident did not include the results of interviews of the other inmates who were present in the tier at the time of Andrewrs death.
5. On March 19, 2006 r inmate John M. was attacked by two other inmates in Tier D-B of Division Xlr which at the time was a maximum security division. Because the officer assigned to Tier D-B was at lunch r and the two closest officers were cross watching Tiers D-B and D-C and Tiers D-A and D-D, the officers had to wait for back-up to arrive before anyone could enter Tier D-B to break up the fight. John M. suffered two puncture wounds to his neck and one puncture wound under his arm. After the fight r officers recovered two steel shanks r a broken caner and three razors from the tier.
c. Contraband and Vandalism
Another indicator of inadequate supervision is the amount of dangerous contraband that is being recovered from the housing units and the ease by which inmates can fabricate homemade weapons. Due to the dilapidated condition of scores of cells r shower areas r and various dayroom features r inmates have ample material for fabricating weapons r including floor tiles r metal from light fixtures r metal from the ventilation systemr glass from cell light bulbs, electrical wiring r and plumbing fixtures. It is virtually impossible for any correctional facility to completely deter inmates from obtaining materials for weapons due to the condition of the physical plant r but the problem at CCJ is/

- 33 -
further exacerbated by the lack of direct supervision in most of the divisions.
Even though the CCJ administration has recently made efforts to curtail the creation of shanks and other weapons through the establishment of a "Weapons Committee," a severe contraband problem still exists. For example, lAD's Contraband Log reveals that, between January 1, 2007 and June 19, 2007, security staff found approximately 484 weapons and shanks. Many of these weapons and shanks were found in inmate cells anddayrooms after a stabbing incident. The Weekly Divisional Reports from February 26, 2007 through June 17, 2007 show an average of 23.5 shanks and 6.6 weapons found each week at CCJ. In just one week, April 2-8, 2007, CCJ staff recovered 55 shanks and 12 weapons. In 2006, lAD opened approximately 590 cases involving shanks, 77 involving weapons, and 115 cases involving other contraband. The number of weapons and shanks is extremely high, even considering CCJ's large inmate population.
During our site visits, we noticed scores of opportunities for inmates to fabricate shanks and other weapons. We found broken and jagged floor tiles laying exposed in dayrooms without raising the notice of staff. In some instances, inmates are using the absence of ventilation grates in their cells to rig a "dumbwaiter" system that allows them to transmit drinking water between the housing unit/s upper and lower tiers from within their locked cells. However/ the inmates can also use these passageways to pass contraband. Shower and bathroom walls in the Residential Treatment Unit ("RTU") that had been damaged by inmate vandalism provided ample opportunity for weapons production and concealment of contraband. We observed numerous vandalized cell lighting fixtures and missing and vandalized cell vents, which are commonly used to create shanks. Inmates/ access to the lighting fixtures can lead to additional dangers. For example/ on June 14/ 2007/ an inmate attempted suicide by cutting himself with a broken light bulb.
In addition to the troubling, unchecked proliferation of weapons at CCJ/ it is clear that there is a serious narcotics problem. Between January 1/ 2007 and June 19/ 2007/ lAD opened approximately 110 cases related to narcotics/drugs. In 2006/ lAD opened approximately 160 cases involving narcotics/drugs.
The lack of adequate supervision at CCJ is further highlighted by the frequent and flagrant rule violations that are evident in almost every tier throughout the facility/ including special management units that should have a higher degree of supervision. For example:

- 34 -
1. Scores of cells have been vandalized and are rife with gang and general graffiti.
2. Scores of cells contain homemade clothes lines. The hanging linens prevent adequate visibility into the cell. Also, the clothes lines can be used by inmates as potential weapons or suicide implements.
3. Small in-cell fires are common. Many inmates use the cell lighting fixtures as an ignition source for warming food and starting fires. Numerous inmates covered the cell light bulb with a milk carton that serves as a lamp shade and an ignition source. In scores of cells, the bottom bunk has evidence of having been heated. Inmates and staff reported that inmates use the bottom bunks as hot plates for warming food by setting a fire underneath them.
4. Scores of cells contain dozens of empty milk cartons and other stored debris that can be used by inmates for improper purposes and provide a potential fuel load in case of a fire.
5. Numerous shower areas have been vandalized, resulting in exposed ceilings and materials that can and are used to fabricate weapons.
6. Numerous inmates use extra blankets as carpets or room dividers for their cell, while other inmates claim a shortage of blankets.
7. Scores of cells, shower areas, bathrooms, and dayrooms have exposed electrical wiring.
8. Scores of vents, window sills, stairwells, and screens throughout the tiers are plugged and covered with debris.
9. As discussed below, many in-use cells are so unsanitary or have such severe maintenance problems that it is clear that adequate security checks are not occurring.
It is common for inmates to try to engage in vandalism or rule infractions, and CCJ could not be expected to prevent all such inmate activities. However, it is not generally accepted correctional practice to allow these violations to occur so flagrantly and with such prevalence throughout the facility.

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The sheer frequency of these issues demonstrates that inadequate supervision is common at CCJ.
d. Inadequate Visibility
Inmate supervision is further hampered by CCJ's physical layout, which does not allow for direct supervision in most divisions. With the exception of the Division II and RTU dormitory units, correctional officers are not stationed inside the housing units. In most divisions, the housing units are supervised by an officer from a tier control center or security entrance post that only allows for observation of the dayroom and some common areas of the housing unit. This is the case even in the special management units, such as disciplinary segregation and protective custody, which is a grossly atypical corrections practice. The officer cannot see into the individual cells while in the control center and is therefore required to conduct frequent physical checks of inmates in their cells. However, security check documentation at CCJ is spotty. For example, during our on-site visits we discovered pre-recorded security checks on housing unit logs and also security checks that were suspiciously logged at precise intervals throughout a shift without any deviation. In addition, numerous inmates throughout the facility reported that officers commonly only enter the housing unit during shift change or meal times, but not on regular rounds throughout the day. This is not surprising, as a single officer may be cross watching two housing units .simultaneously from one control center.
Even if security rounds within the housing units are occurring as scheduled, lack of visibility into cells is a major safety concern. Scores of cells are dark due to inoperable lighting fixtures, missing light bulbs, or inmate vandalism of lighting fixtures. We also observed the results of rampant vandalism of the lighting system in the RTU dormitory units, despite the fact that an officer is purportedly posted inside each RTU dormitory at all times. In fact, one RTU dormitory had no working lights and another had only two or three working lights, out of 24 light fixtures. Lack of operable lights makes the entire unit dangerous both for inmates and officers. This problem is compounded by the fact that correctional officers cannot replace broken or burned out light bulbs, but must issue a work order and wait for Facilities Management to handle the request. In addition, we observed many cells and shower areas with "privacy curtains" and with the celldoor windows obscured by cardboard, paper, towels, and other materials. It is very difficult, if not impossible, for officers to provide adequate safety and security checks of inmates when they cannot see into

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the cells and shower areas. Compounding the lack of adequate inmate supervis~on within the housing units is the fact that cells are not equipped with intercoms or emergency call buttons, which are useful safety and security features designed to allow for a locked inmate to alert an officer in an emergenCy situation. Intercoms or emergency call buttons are especially important for special management units, where the inmates spend approximately 23 hours of the day locked inside their cells, often alone.
Of particular concern for inmate and officer safety is the lack of visibility in the Special Incarceration Unit of Division IX. As these cells house CCJ/s highest risk offenders and inmates with demonstrated behavior ,problems, the celldoor windows have been modified to prevent inmates from throwing liquids or objects at officers. However, instead of installing a protective covering that would allow for observation, such as safety glass, CCJ welded a metal plate with small holes in it on to the cell windows in the Division IX Level 4 tier. As a result, it is virtually impossible to see into the cell, especially at night.
In addition to inadequate interior security visibility, during a night time tour of CCJ/ we observed approximately 22 external post and building lights that were not functioning in the area between Division I and Division V. This is unacceptable and a significant security risk.
e. Inadequate Security Policies and Procedures
At CCJ/ each separate division has Standard Operating Procedures (~SOPs") that cover all the necessary components for a security program, such as key control, cell locking procedures, incident reporting, and search procedures. During our review, we found that while some CCJ policies and procedures were up to date, many were not. Generally accepted correctional practices require that post orders should be reviewed on a quarterly basis. CCJ policy requires that post orders be 'reviewed annually. We reviewed the post orders available at various security posts throughout CCJ and found many post orders that had not been reviewed in multiple years. For example, in Division XI, we inspected a manned gun tower. The post order for the tower was dated January 1996 and was last revised on January 15/ 2003. In addition to being outdated, the post order did not contain essential information for an armed post/ including instruction on when and under what circumstances the weapon should be used. CCJ is also lacking in proper policies regarding inventory of security equipment, including the newly, introduced OC spray, which could allow for unaccounted misuse by correctional

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officers. When post orders are not updated regularly and do not address vital information, facility practices will develop in an ad hoc nature and will not account for current needs. Outdated policies, procedures, and post orders are inconsistent with generally accepted correctional standards and contribute to a failure of the overall security system.
Although CCJ policies must adapt to some extent to account for the different security levels and different physical layouts in the various divisions, there is widespread policy variation from division to division on issues ranging from the handling of grievances to incident reporting. This can be confusing for correctional officers, who rotate posts every 90 days and may be transferred from one division to another without adequate training on division-specific SOPs. Policy discrepancies abound division to division, which result in widely different security practices. There is no standardized format in use throughout CCJ for division Roster Staffing Reports and Post Analysis Reports. Even CCJ's top level administration is unclear how security procedures are implemented throughout the facility. For example, a high level security official told us that each and every inmate should be patted down when he or she returns from the recreation yard. However, Division I supervisors reported that inmates are only subjected to pat downs at random upon their return from the yard.
An additional area of policy concern is with regard to special management units, which include the Special Incarceration Units, disciplinary segregation, and protective custody units. Generally accepted correctional practices require that officers who are assigned to these types of units possess a higher level of detention experience, receive focused training in special management operations, and are reg~larly assigned to these units for stability purposes. Correctional officers in CCJ's special management units rotate on a regular basis and do not receive specialized training for working with high risk inmates. This practice should be changed at the policy level.
f. Disciplinary Process
CCJ operates the inmate discipline component with a policy and procedure that appears to be adequate and provides sufficient due process to inmates. However, we did note some concerns with regard to the disciplinary process. First, hearings are not consistently conducted in a private, confidential manner and secure setting in accordance with generally accepted correctional standards. During our, observation of the disciplinary hearings in Division II, 12 inmates were brought into a la~ge room and

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seated together for their individual disciplinary hearings, including inmates whos~ disciplinary charges involved incidents of violence against each o.ther. The proceedings were conducted within hearing of the other inmates. This process certainly presents safety and security issues because there may still be animosity between inmates whq were involved in an altercation. For example, on July 26, 2007, two inmates began fighting during a disciplinary hearing in the Division VI library, and required medical care. Also, the victim may be reluctant to be truthful during the hearing for fear of retaliation by the aggressor. In addition, we noted that the statements made by the inmates during the hearing are written down by the disciplinary board in a very abbreviated fashion that may not adequately represent the inmates' statements.
3. Deficient Classification Procedures
All inmates admitted or discharged from CCJ are processed in the RCDC. The RCDC is located in the basement of Division V, and was originally designed as a storage area. Instead of storage, it holds several hundred inmates as they are strip searched, processed through booking, fingerprinted, photographed, screened for medical and mental health problems, and assigned to a bullpen until they can be. transferred to their appropriate divisions. Almost every evening, the RCDC bullpens hold hundreds of inmates, for several hours at a time, who are crowded shoulder-to-shoulder behind chain link fences so tightly that there is insufficient space for them to sit or lie down. There is one female bathroom and only one male bathroom, with two toilets, and no hand washing facilities, for hundreds of male inmates to share. 28 While the RCDC overflows with hundreds of inmates, a surprisingly small number of correctional officers attempt to perform a multitude of duties, including the supervision of inmates. In addition to the natural stress resulting from admission to jail, inmates upon booking, who may have been held for multiple days in various police departments before arriving at CCJ, can be medically and mentally unstable. Newly admitted inmates are very unpredictable. The overcrowded, disorganized, and understaffed RCDC is a major security and safety risk to staff and inmates.
28 On January 14, 2008, the Sheriff's Office sent us photographs of recent renovations to the RCDC bathroom, including six new sinks and five new urinals. This is a vast improvement r but the single bathroom and limited toilets is still problematic r given the immense number of inmates in the RCDC each evening.

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The John Howard Association found the RCDC "grossly inadequate in size, design, and virtually every other respect."29 We concur. The Sheriff's Office and the County concede that the RCDC physical plant is inadequate and we understand that funds have been allocated for construction of a new RCDC and RTU, but the new facility will not be completed until late 2009, at the earliest. 30
Classification problems do not end with the physical plant of the RCDC. The Sheriff's Office admits that the present classification system is "extremely obsolete."31 The system was purchased in 1991 and last updated in 1993. It is an antiquated inmate tracking system that is incapable of tracking basic information, such as the number of empty beds in each CCJ division at any time. The RCDC Superintendent is required to make telephone calls on a constant basis to the other divisions in order to ascertain the bed availability. Although the RCDC Superintendent has access to e-mail, the superintendents of the other divisions do not.
The classification system contains provisions for initial custody assessment and for custody re-assessments. However, although CCJ uses a Special Incarceration Unit "level system" to manage high risk inmates and security threat groups, that information is not contained within the classification policies and procedures manual.
Perhaps more troubling than the obsolete nature of the CCJ classification system is the fact that many supervisors do not understand how to properly uti.lize the system. Midway through our second site visit to CCJ, we learned that information on each inmate's classification status and history is readily available from terminals in every division. However, many CCJ supervisors and even division superintendents had previously reported to us that they could not access such information on the system. The superintendent who revealed the broader tracking capabilities to us acknowledged that many CCJ supervisors are not proficient with the CCJ system.

29

2007 Court Monitoring Report at 67.

30 President Todd H. Stroger and the Cook County Board of Commissioners' Status Report, Duran v. Dart, No. 74-C-2949, at 8 (N.D. Ill. June 11, 2007).

31 Sheriff's 2007 Status Report and Response to John Howard Association Court Monitoring Report, Duran v. Dart, No. 74-C-2949, at 22 (N.D. Ill. June 11, 2007).

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Given the high level of inmate assaults and gang-related violence at CCJ, it is clear that inadequacies of the classification system are contributing to CCJ's securi.ty deficiencies.
4. Inmate Grievance Procedure
An inmate grievance system is a fundamental element of a functional jail system, intended to provide a mechanism for allowing inmates to raise conditions of confinement related concerns and issues to the administration. If viewed as credible by inmates, it can also serve as a source of intelligence to staff regarding potential security breaches as well as staff excessive force or other misconduct. The grievance system should be readily accessible to all inmates. Inmates should be able to file their grievances in a secure and confidential manner and without the threat of reprisals. Staff responsible for answering inmate grievances should do it in a responsive and prompt manner. Unfortunately, we noted ,a number of serious concerns with the inmate grievance process at CCJ.
The primary responsibility for coordinating and responding to inmate grievances lies with the Correctional Rehabilitation Workers ("CRWs"). Each of the approximately 40 CRWs, if evenly distributed throughout CCJ, has a caseload of well in excess of 200 inmates, which is extremely ambitious. Although management staff expect that the CRWs conduct at least two visits to each of their assigned units per week to collect grievances and to perform other duties, this is not occurring on a consistent basis. Moreover, numerous inmates complained that they do not have aCCess to the CRWs (and consequently, the grievance process) if they are locked in their cells when the CRWs conduct rounds, which is a common occurrence.
At the divisional level and by divisional policy and procedure, there are supposed to be locked grievance boxes in the housing units for inmates to place their grievances in. The CRWs are supposed to collect the grievances from the locked boxes each weekday. However, the grievance system functions differently in practice, and varies from division to division and even from tier to tier. Although it is not reflected in the written policies, the prevailing current practice is :for the inmate to give the completed grievance to the CRWs when they cond~ct rounds. Staff reported that inmate grievances are to be inserted in confidential envelopes and sealed by the inmate, which is also not written in the divisional policies. In some divisions, an inmate can also give the completed grievance to a security supervisor, who will record it in a log and give it to a CRW. In

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other divisions, security staff refuse to handle any grievance, to avoid conflicts and the appearance of impropriety. In yet another version, inmate grievance forms are kept and passed out only by the CRWs and completed forms are collected by the block sergeant and brought to the CRWs' office. Although most of the divisions are not using the grievance boxes, many staff members, including the Program Services Administrator, were under the impression that inmates were using the boxes. There is an extremely high level of confusion regarding the grievance policy and practice at all levels of CCJ.
In addition, access to grievance forms by inmates is a universal problem. Although many management staff believe that the grievance forms are available on the tiers, this is simply not the case. The vast majority of the units that we visited during our June and July 2007 site visits did not have inmate grievance forms or confidential envelopes available on the housing units. Grievances forms are not available in Spanish language, despite the fact that many CCJ inmates can only speak, read, and understand the Spanish language. 32
We also found that inmates believe the grievance process is unreliable and repeatedly complained about its effectiveness, with reason. For example, inmates stated that grievances relateq to the use of force generally result in one of two inadequate responses. Sometimes an investigator will speak to inmates after they file use of force grievances, but the inmates stated that they never heard back about their grievances. Most inmates complained that they heared nothing at all in response to a use of force grievance or received a summary denial. Inmate Byron S. filed a grievance approximately one month after an officer broke his jaw in January 2006. Thirteen days later he received a one sentence response to his grievance stating that there would be no lAD investigation because Byron had been found to have "assaulted and battered staff. . as detainee was combative." In fact, although the officer initially reported that he was attacked by inmates, the officer admitted he had fabricated the story weeks before Byron filed the grievance. lAD filed a complaint against the officer for falsification of a report, yet the response to Byron's grievance, over a month later, was factually inaccurate according to CCJ's own records. Moreover, the grievance did not trigger an investigation. CCJ opened ,the investigation seven months later! after Byron filed a lawsuit.
32 See Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d et ~

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5. Access to Infor.mation
Generally accepted correctional practice requires that newly admitted inmates are given an opportunity to learn about the facility rules and regulations, services that are available, policies and procedures that affect the inmate, and facility schedules. Each inmate should receive a facility handbook, containing all the relevant information, and should have an opportunity to have the information explained to him or her if the inmate cannot read. Most facilities have a formal orientation procedure as a part of the intake processing. At CCJ, officers reported that they offer inmates a copy of the inmate handbook in the RCDC. There is no documentation as to whether a handbook is offered or accepted. Although there was a small stack of inmate handbooks behind a counter in the RCDC strip search area, we did not observe a single inmate of the hundreds present in the RCDC area with a CCJ handbook during either of our site visits.
B. INADEQUATE MEDICAL CARE
Jail officials are responsible for providing adequate medical care to inmates. Moreover, a jail may not deny or intentionally interfere with medical treatment. A delay in providing medical treatment may be so significant that it amounts to a denial of treatment. Our investigation revealed that medical care provided at CCJ falls below the constitutionally required standards of care. We found the following deficiencies: (1) inadequate medical staffing; (2) inadequate intake screening; (3) inadequate health assessments; (4) inadequate acute care; (5) inadequate chronic care; (6) inadequate emergency care; (7) inadequate record keeping; (8) inadequate medication administration; (9) inadequate management of communicable diseases; (10) inadequate access to medical care; (11) inadequate medical facilities; (12) inadequate dental care; and (13) inadequate quality assurance.
1. Inadequate Medical Staffing
CCJ lacks the medical staff necessary to provide adequate medical services. Generally accepted correctional standards of care require that facilities maintain adequate staffing to provide inmates with necessary medical care. Many of the problems identified below are exacerbated by the inadequate medical staffing. In early 2007, there were significant health care cutbacks at CCJ, including 23 clinical positions (four physicians and three dentists), nine management positions, and 16 other health care positions. These cutbacks have severely

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impacted the quality and timeliness of medical care at CCJ. Most notablYr the nursing staff shortages r which have left many divisions understaffed during periods of the daYr and the dental staff shortages have caused or aggravated inadequate medical services.
2. Inadequate Intake Screening
CCJ fails to adequately identify inmates r urgent and/or ongoing health needs through appropriate intake screening. Adequate intake screening is essential for ensuring that inmates are receiving proper care for acute or chronic needs. Generally accepted correctional medical standards require that incoming inmates be screened by staff trained to identify and triage serious medical needs, including drug and alcohol withdrawal r communicable diseases r acute or chronic needs r mental illness r and potential suicide risks. CCJrs intake screening fails to identify such needs and increases the risk of serious harm.
At CCJ, correctional medical technicians are responsible for conducting intake screenings. If an inmaters intake screening is positive for a possible acute or chronic condition r the inmate should be referred to a physician assistant for an evaluation. Nationwide r more than 30 percent of inmates have acute or chronic conditions that would require a medical or mental health evaluation on the first day at a correctional facility.33 In contrast r only 15 percent of the 100 intake screening records we reviewed during our June 2007 on-site visit resulted in a referral for evaluation. During our July 2007 on-site visit r we reviewed 120 intake screening records and found that only six of the inmates were referred to the physician assistant. These numbers depart significantly from what would be expected in CCJrs inmate population r which strongly suggests that the CCJ intake screening process is incomplete and inadequate.
Screenings take place in an area of the RCDC that is chaotic, noisYr and crowded. The screening interviews often occur while inmates are handcuffed together r resulting in a total lack of privacy, which compromises the quality of information received. Further r CCJrs screening form is deficient because it lacks sufficiently specific questions regarding acute and chronic illnesses r including drug and alcohol withdrawal. We found several instances where acute and chronic medical needs were not
33 National Commission on Correctional Health Carer The Health Status of Soon-to-be-Released Inmates: a Report to Congress (May 2002). http://www.ncchc.org/pubs/pubs_stbr.html.

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recorded on intake. These practices contravene generally accepted correctional medical standards, and place inmates at significant risk of harm.
For example, we identified the following cases of intake screening deficiencies:
a. Nadia H. died in late 2006, one day after being booked into CCJ, likely of withdrawal syndrome. 34 During intake, she reported a history of heroin addiction, yet staff failed to document her drug use and history of addiction. Despite knowledge that Nadia had a history of addiction, staff disregarded her emergent condition and placed her in general population. The next day she was found dead in her cell.
b. Julia G. was booked into CCJ in 2007 with a history of alcoholism and a dangerously high blood pressure. The screening process failed to identify that she was at risk of developing delirium tremens, a potentially life-threatening, but preventable, complication of alcohol withdrawal. Instead of evaluating and treating her medical condition, she was transferred to general population, where she developed delirium tremens and had to be admitted to the hospital. She also had comorbid hyperthyroidism, which should have been detected during the intake screening. Because of CCJ's inadequate screening, Julia was at a very high risk of death.
c. In June 2007, David M. was booked into CCJ with a history of heart disease, deep vein thrombosis, depression, and recent trauma. Despite his serious medical history, he was neither examined by a physician assistant nor did he receive any medical care. Even after informing CCJ personnel on several occasions that he was currently taking a prescription for Coumadin (a blood-thinner prescribed for those at high risk for a blood clot and for some heart conditions), it took staff over three weeks before David finally received his first dose of Coumadin.
34 We reviewed the medical records of 20 inmates seen by the physician assistants in the intake area on June 18, 2007, and found that none of the inmates were asked about a history of alcohol withdrawal syndrome, a life-threatening condition that is common among inmates.

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d. In June 2007, Lyle P. was booked into CCJ. At intake, Lyle reported his HIV infection and his strong adherence to his medication regimen, but he did not receive his medication prescription. Nearly two weeks passed before he was finally seen by an infectious disease specialist. Because of the two week lapse in medication, the specialist chose to delay treatment, which further enhanced the risks for Lyle to develop potentially-fatal drug resistance.
e. During our July 2007 on-site visit, we encountered an inmate who suffered from a recent facial trauma, including redness, swelling, and abrasions on the left side of his face. He complained of visual disturbances and discomfort over the entire left side of his face during intake, yet he was not examined by medical staff. It was only after we brought his condition to CCJ personnel that he was re-evaluated by medical staff.
3. Inadeguate Health Assessments
CCJ does not give its inmates an adequate health assessment within a reasonable period after admission. The generally accepted standard of care is to conduct a health assessment within fourteen days of admission, or sooner when medically indicated. This assessment typically includes a review of intake information, a <complete medical history, a physical examination, and screening for tuberculosis (UTB") and sexually transmitted diseases (USTDs"). Appropriate and timely health assessments are particularly critical should screening procedures fail to identify an inmate's serious health needs and improves the facility's ability to provide efficient and adequate care.
The great majority of inmates admitted to CCJ do not receive a health assessment within a reasonable period after admission. Many inmates never receive a physical examination at all. Even inmates who were appropriately referred to the physician assistants upon intake did not consistently receive appropriate referrals for follow-up or assessment. 35 The necessity for a full health assessment is underscored by the grossly inadequate intake screening process. In addition to the risk to individual inmates with untreated conditions, CCJ's failure to conduct health
35 The physician assistants in intake spend approximately five minutes per patient and conduct very cursory examinations without privacy or an appropriate facility.

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assessments puts all inmates and staff at risk from the spread of disease.
4. Inadequate Acute Care
CCJ fails to provide adequate and timely acute care to inmates with serious or potentially serious acute medical conditions. CCJ's acute care services substantially depart from generally accepted correctional medical care standards. We identified grossly inadequate acute care that led to prolonged suffering and premature deaths of inmates at CCJ. Acute care was so deficient that inmates suffered needlessly because medical staff failed to ensure that inmates met scheduled-appointments, failed to monitor acute conditions, and failed to timely treat inmates' conditions. We found numerous instances where CCJ's failure to adequately assess and treat inmates likely contributed to prevehtable deaths, amputation, hospitalizations, and unnecessary harm. 36
The following examples highlight CCJ's deficiencies in providing acute care:
a. In early 2006, Gloria D. died after not receiving adequate care for an emergent and life threatening condition. Gloria, who suffered from human immunodeficiency virus ("HIV"), was admitted to CCJ in early 2006. After one month in the facility, staff ordered an x-ray after Gloria complained of persistent cough and shortness of breath. Although her x-ray was abnormal, Gloria did not receive any follow up care. Less than three weeks after her abnormal x-ray, Gloria developed a fever, tachycardia,37 and low oxygen saturation. Gloria was hospitalized and died of untreated Pneumocystis carinii. 38

36 Our medical chart review was hampered by CCJ's highly disorganized and incomplete medical records. For example, 72 percent of the records we requested for inmates sent to hospital emergency rooms were unavailable. While the medical records deficiencies hindered our review, we were still able to document serious lapses in medical care.

37

Tachycardia is a rapid heart rate, over 100 beats a

minute, which can be caused by cardiac arrhythmia.

38 Pneumocystis carinii is an opportunistic but preventable infection that occurs in immunosuppressed populations, primarily HIV patients with advanced infection.

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b. In July 2006, Manuel M. was admitted to CCJ with a life-threatening blood pressure reading, an elevated pulse, and a history of alcohol use. Although he was medicated and monitored daily for hypertension, he was not treated for alcohol withdrawal and, on his third day at CCJ, exhibited tremors and an altered thought process, signs of delirium tremens. He should have been hospitalized at this point, but was not. On his sixth day at CCJ, when his blood pressure decreased some from its previously high levels, he was put in general population. He was never treated for delirium tremens and committed suicide while delirious.
c. In August 2006, inmate Aaron B.'s leg was amputated as a result of a bone infection resulting from CCJ's failure to provide adequate acute care. On August 8, 2006, Aaron was admitted to CCJ. He arrived at CCJ with a soft cast on his leg. Medical staff removed the so£t cast and replaced it with a hard cast. Aaron complained of constant pain for nearly a week before he was finally seen by a physician on August 14. The physician scheduled an immediate orthopedist appointment for August 16. Unfortunately, Aaron never saw the orthopedist because the orthopedist refused to treat Aaron without his medical chart, which CCJ staff did, not provide. After complaining of discomfort and a malodorous discharge dripping from his hard cast, on August 31, he was admitted to Cermak infirmary with osteomyelitis (an acute or chronic inflammatory process of the bone). His leg was later amputated because the severe infection had destroyed substantial soft tissue.
d. In late 2006, Aidan A. died after suffering from sepsis. 39 He was admitted to CCJ after suffering from a gunshot wound in his arm. His wound was surgically repaired and he had metal inserted in his arm to set the bone. The orthopedist scheduled an appointment so that the metal insert could be removed, but CCJ failed to take him to the hospital for his scheduled appointment. After seven weeks at CCJ, Aidan developed a deep tissue infection which elevated his respiratory rate and his pulse rate became dangerously high. By the time he was finally taken to the hospital, it was too late to contain the infection and Aidan died at the
39 Sepsis is the presence of bacteria or other infectious organisms or their toxins in the blood or in other tissue.

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hospital, of sepsis two months after his admission to CCJ. This was a preventable death.
e. Five days after his 2007 intake to CCJ/ Henry H. had a new/ on-set seizure and suffered a fractured jaw during the incident. It took six days for him to be seen by an oral surgeon and he was never evaluated for the cause of his seizure/ as he should have been.
5. Inadequate Chronic Care
CCJ fails to provide adequate care to inmates with serious medical needs that require monitoring and follow-up medical care. Inmates who suffer from chronic medical illnesses must be regularly monitored by medical professionals to prevent the progression of their illnesses. Monitoring should occur on a regular basis to ensure that symptoms are under control and that medications are appropriate based on generally accepted correctional medical standards. However/ we found that CCJ was deficient in ensuring that patients are seen on a regular basis/ that medications are timely distributed/ and that inmates are monitored and treated to prevent the progression of illnesses.
Specifically/ in examining a sampling of medical records of inmates with chronic conditions/ we found the following instances of deficient chr.onic care:
a. In reviewing the records of ten CCJ inmates with diabetes/ we looked for seven nationally accepted interventions. 40 Inadequately monitored diabetes can lead to stroke/ vision loss/ diseases that effect the feet and muscles/ kidney damage/ coma/ and death. In a gross departure from generally accepted correctional standards/ none had a documented urinary microalbumin within the last 12 monthsi only two had a measurement of A1c hemoglobin within the past three monthsi four had a cholesterol measurement within past yeari two were on aspirin prophylaxisi and two had a dilated retina exam. Our review of these files revealed that CCJ was not adequately monitoring these inmates through
40 These interventions are: measurement of sugar levels upon intake/ measurement of urinary microalbumin/ dilated examination of the retina/ cholesterol measurement/ measurement of A1c hemoglobin/ chronic care visit with physician/ and aspirin therapy.

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chronic care visits or consistently screening them from the conditions that they are at risk of developing.
b. We reviewed the treatment of 14 inmates suffering from moderate or severe asthma. Chronic follow-up care and regular monitoring of peak expiratory flow (a test that measures how well the airways are working) are critical in the proper care for persons with asthma. We found five of the 14 inmates had not been seen for chronic care within the last three months and only seven of the 14 had any measurement of their peak expiratory flow. We also requested records of 13 inmates seen in the Cermak emergency room for acute asthma between March 5 and May 2, 2007. None of these patients had follow-up to see if they were improving. 41
c. Similarly, we requested the records of 15 inmates at the facility who are on the blood thinner Coumadin. This medication has very narrow therapeutic rangei if an inmate is given too little, the medication will be ineffective, but if the medication is given too much, he or she will experience substantial detrimental effects. Accordingly, frequent measurement of the blood-clotting ability of patients taking Coumadin is critical. Of the records we requested, two were lost, one inmate was not scheduled for follow up for eight weeks, instead of the typical one to two weeks, and another inmate did not have necessary laboratory tests at intake. Inmates who are taking Coumadin but who are not monitored appropriately are placed at risk for a potentially life-threatening blood clot or a hemorrhage.
d. We also reviewed the records of five paraplegic inmates who suffered skin breakdowns, skin ulcers (bed sores) , or wound infections. Our expert consultant found patterns of egregious failures of care regarding wound care in each of these cases. In one startling example, we reviewed the chart of inmate wallace G., who suffered a skin breakdown. An x-ray revealed that his initial skin breakdown caused a soft tissue infection which likely caused a bone infection. Despite the abnormal x-ray, we were unable to find any follow-up care, treatment for the condition, or assessment by the
41 Only 23 percent of the records requested were available and only one of those charts contained the emergency room record.

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physician. These failures are gross deviations from generally accepted correctional medical standards. 42
6. Inadequate Emergency Care
-,
CCJ fails to provide adequate emergency care. We observed an emergent incident during July 2007 on-site visit, when we encountered a male inmate who was known by CCJ staff to have a history of heart disease. While we were on his housing unit, inmate Mitchell H. experienced severe heart complications and lost consciousness. Although the dispensary nurse responded to the emergency call, it took 15 minutes for the ambulance and EMT to arrive. While the dispensary nurse was struggling to revive Mitchell, the EMTs were chatting and inattentive to Mitchell's needs. After nearly 45 minutes of suffering severe chest pains, Mitchell was finally placed in the ambulance. CCJ's slow response does not comport with generally accepted correctional medical standards and placed this inmate at risk of serious harm.
We found additional instances of deficient emergency care that put inmates' health and lives at risk. As part of our review, we randomly selected five inmates who were seen in the Cermak emergency room for alcohol withdrawal sYmptoms in the spring of 2007 and concluded that CCJ's treatment and assessment was deficient in four out of five cases. Two of the inmates were sent to the emergency room because of their significant elevations of blood pressure. In both cases, CCJ staff neither treated their high blood pressure nor adequately monitored their condition. Rather, CCJ sent both inmates back to general population without a thorough examination. Two other inmates were seen in the emergency room, but we were unable to find emergency room notes that documented any treatment. 43 The last inmate received no treatment because he suffered from asthma and did not require treatment for alcohol withdrawal.
7. Inadequate Medication Administration
We found numerous systemic problems with medication administration and management. CCJ frequently fails to:
42 Our expert consultant advised CCJ of this patient's inadequate care during our July 27, 2007 exit conference.
43 CCJ has a responsibility to obtain discharge summaries or notes from the hospital when inmates are treated at outside facilities in order to adequately assess and treat inmates upon their return to CCJ.

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(1) verify identification of inmates receiving and ingesting medication; 2) provide critical medications to inmates without delay or lapses; and (3) maintain inmate medication administration records (~MARs") concurrently with distribution.
Generally accepted correctional medical standards require that facilities administer medication and maintain adequate medication records to meet the medical needs of the inmates and to prevent medication errors and other risks of harm. Regular and systematic reviews of medication usage is also required to ensure that each inmate's prescribed medication regimen continues to be appropriate and effective for his or her condition.
During our on-site visits, we observed the distribution of medication in each of the CCJ divisions. In every instance, we found nurses throughout the facility who failed to verify inmates' identification before administering medication. This deficient practice increases the chances of dispensing medications to the wrong inmate or dispensing medication to an inmate who may have an adverse reaction to medication. Also problematic was the failure of nursing staff to observe inmates swallowing prescribed medication. This failure prevents nursing staff from accurately recording administered medications and creates an unsafe and potentially dangerous environment where medication could be hoarded, sold, or result in overdoses. The nurses' failure to verify identification and observe inmates swallowing medications is inconsistent with generally accepted professional standards of correctional medical care and greatly increases the risks for error and harm.
Our investigation also revealed significant delays, errors, and lapses in medication administration, all of which have contributed to needless suffering and inmate hospitalizations. The following examples illustrated the medication administration deficiencies:
a. As discussed above, David M. was booked into CCJ in June 2007 with a prescriptioD for the blood thinner Coumadin, but there was a 22-day delay before he finally received his first dose of Coumadin.
b. In May 2007, Roy H. was booked into CCJ. He was admitted after a kidney transplant. He was prescribed medication to prevent .his body's rejection of his kidney transplant. After 16 days without his prescribed medication, he had to be hospitalized because his body began to reject his kidney and he

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developed metabolic acidosis, a potentially life-threatening condition. 44
c. In 2007, Gregory T. was booked into CCJ after a hospitalization for deep vein thrombosis. Although he had a prescription for Coumadin, CCJ staff failed to order his prescription. For nearly 20 days, he needlessly suffered. He developed a blood clot in his leg and had to be hospitalized because of CCJ's failure to order his prescribed medication.
d. In 2007, Stella R. had a prescription for Coumadin and a prescription for hypertension medication, yet CCJ staff failed to order her prescriptions. Stella went nearly 20 days without her prescriptions. It was only after we brought this medication error to CCJ's attention that Stella had her prescriptions ordered.
e. In 2007, Rebecca N., an HIV-positive inmate, had a prescription for antiretroviral medication, but CCJ staff failed to administer her medication daily as prescribed. There was a five-day lapse in her medication, which is especially dangerous for inmates with HIV.
f. In 2007, Grant P. suffered head trauma during seizure, which was likely caused by his not receiving 11 of his 31 prescribed doses of his anticonvulsant medication.
We also found deficiencies in CCJ's MARs. Contrary to generally accepted correctional standards, numerous MARs were not contemporaneously completed or signed as medication was distributed. CCJ medical staff often left records blank or failed to log critical clinical information upon distribution of medication to inmates. We spoke with a medication technician who told us that because of staffing problems in several divisions it was virtually impossible to distribute medications and document MARs at the same time. This practice is inconsistent with generally accepted professional standards of correctional medical care and greatly increase the risk of error.
We also reviewed a sampling of MARs during our on-site visits and found that approximately 15 percent of the MARs were blank which made it difficult to determine if inmates were receiving medications as prescribed. In Division IV, we found
44 Metabolic acidosis is a clinical disturbance characterized by a relative increase in total body acid.

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particularly high level of blank MARs. When we spoke to the nursing staff on the division, we learned that Division IV was severely understaffed. Further, we learned that staffing shortages had resulted in the division and nurses being unable to dispense medications in the afternoon or evening. Inmates were forced wait until the morning before they were able to get their medications. Similarly in Division III, we learned that medications were not delivered because of staffing shortages and inmates were not receiving medications as prescribed. Blank MARs are indicative of inadequate training, supervision, and staffing.
8. Inadequate Infectious Disease Control
CCJ fails to adequately treat, contain, and manage infectious disease. This failure is dangerous and places inmates, staff, and the community at unnecessary risk of serious health problems. CCJ's management of TB, Methicillin-resistant Staphylococcus aureus ("MRSA") ,45 and other infectious diseases deviates from generally accepted correctional medical standards. Inmates with infectious diseases are not appropriately contained, treated, or managed. The overcrowding, poor ventilation, and constant exposure of inmates to each other and CCJ staff are conditions conducive to the spread of disease. CCJ's containment and management of infectious disease substantially departs from generally accepted correctional medical standards.
CCJ fails to ensure adequate containment of TB. Once TB has been identified, treatment must be initiated and monitored; Inmates believed to have infectious TB should be placed in specialized respiratory isolation ("negative pressure") rooms to reduce the risk of transmission through airborne particles. Isolation rooms are essential to the prevention of contagion. These isolation rooms should be tested to ensure proper ventilation. In addition, staff who are potentially exposed, to the risk should wear masks and be trained in the use of specialized respirators. We found that CCJ does not comply with these generally accepted correctional standards.
The most egregious example of CCJ's failure to provide adequate containment of TB is inmate Wallace G. Wallace was housed in a respiratory isolation room because of his abnormal chest x-ray and a history of TB. The room purportedly had negative pressure to contain any TB organisms. However, we
45 MRSA is a potentially dangerous drug-resistant bacteria that can cause serious systemic illness, permanent disfigurement, and death.

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inspected the respiratory isolation room and discovered that the room did not contain negative pressure. A correctional officer was stationed outside the hallway to the negative pressure rooms, in order to ensure that people entering the area wore proper masks, but the doors to the area were propped open. Immediately following our discovery of the possible inadequate containment, we informed CCJ personnel of our finding and the potential health risks. CCJ staff later moved Wallace to another respiratory isolation room that contained negative pressure.
Thereafter, we inquired into whether CCJ was following the Centers for Disease Control and Prevention's recommendations for containment of TB. The recommendations require facilities to check respiratory isolation rooms monthly, and daily when rooms are occupied. 46 We found that neither CCJ, Cermak, nor Facilities Management Department inspect the isolation rooms. This oversight exposes staff and other inmates to a high risk of TB infection.
Similarly, CCJ fails to provide adequate management of skin infections. Consistent with generally accepted correctional practices, jails should adopt a skin infection control plan to guide the prevention of transmission of skin infections, including drug-resistant infections such as MRSA. MRSA transmission can be prevented by early identification, effective treatment, wound care, follow-up, environmental controls, and efficient laundry practices. We found serious deficiencies in these critical areas at CCJ.
CCJ lacks an adequate tracking system to ensure that skin infections are properly treated. We learned that CCJ had a nurse practitioner responsible for wound care and tracking patients with skin infections, but she did not record any of her findings in inmates' medical records. Without an adequate tracking system, inmates with infections are not properly treated and the risk of transmission increases significantly. Similarly, we found that the CCJ laboratory did not report diagnostic cultures of skin infections to the nurse practitioner. A culture, which is an examination of a sampling of cells taken from the affected area, may be done to identify the microorganism causing the skin infection and to determine the antibiotic or other treatment that will effectively treat it. Without wound cultures, it is impossible to recommend appropriate antibiotics and increases the risks of harm.
46 http://www.cdc.gov/mmwr/PDF/rr/rr5509.pdf

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Laundry is also an important component to prevent the transmission of infection. Inmates should have access to clean underwear and regular changes of uniform. CCJ launders inmates' clothing once per week, thereby increasing the risk of infection transmission. Inmates informed us that the only way to maintain clean underwear is to wash it themselves in sinks and toilets in the cell area. We observed uniforms, underwear, and linen hanging to dry throughout the cell area and on railings and dayroom window ledges on every division. These deficient practices greatly increase the risk of intramural transmission of skin infections.
9. Inadequate Record Keeping
CCJ fails to maintain complete, accurate, readily accessible, and systematically organized medical records. CCJ lacks an adequate medical records system to ensure that inmates' records are correct and accessible so that physicians can provide appropriate care.
CCJ's medical records system is strained and overflowing with unfiled and inaccurate medical records. For example, there is a three month backlog of unfiled medical records in the central medical records room; a two month backlog of unfiled emergency room records; and a three to 14 month filing back log of medical records in various CCJ divisions. The backlog of unfiled records seriously interferes with the continuity and coordination of care at CCJ. This inefficient filing system greatly increases the risk of error in treatment, assessment r and care. Further, the current system does not facilitate a system for coordinated treatment by multiple providers because inmates' records are not accurate, organized or timely filed.
We found records throughout the facility with critical medical information missing. For example, as discussed above, although inmate AaronB. was scheduled to see the orthopedist for his serious knee injury, the physician refused to treat Aaron because CCJ could not find his medical chart. Aaron's leg was subsequently amputated because of a serious infection that developed due to inadequate care resulting from a chart that was missing in the medical record.
The inadequate record system is further impeded by clinicians who created ~shadow charts." Physicians kept lists, logs, or filed copies of progress notes and diagnostic reports in their desks so that they could properly monitor their patients' progress. While the concept of creating shadow charts might seem to enhance continuity of care, they actually create another

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barrier for maintaining accurate, complete, and accessible medical records. In most instances, physicians maintained notes, lists, and logs that were not updated in central records, which further created a gap in maintaining complete records.
Our investigation also revealed that medical records were not readily accessible. For example, we found that clinicians did not have access to inmates' records maintained in the divisions after 3:00 p.m. because the medical records rooms were locked at that time due to staffing problems. This lack of medical continuity and coordination of care seriously interferes with the clinician's ability to manage medical emergencies outside of the Cermak units.
10. Inadequate Access to Medical Care
The CCJ sick call process fails to provide adequate access to medical care. CCJ inmates access medical care by completing sick call requests. Although CCJ correctional staff are responsible for collecting sick call requests, inmates reportedly make multiple requests before receiving medical care. Our review of medical records confirmed that many inmates made several requests for care before receiving treatment. For example, on July 25, 2007, inmate Jackson E. requested medical treatment for staples that had been left in his scalp and sutures that had been left in his arm. Although he made several requests to have the staples and sutures removed, he did not receive treatment, even after our consultant alerted CCJ staff to his condition. He reportedly was placed in lock down for ten days for making repeated requests for medical care. It is inappropriate to punish inmates for requesting medical care. Similarly, inmate Donald C. made repeated unanswered requests for medical care for eye hemorrhages and lacerations he sustained in an altercation with custody staff.
Also of concern, inmates reported that they were limited in their ability to access medical care by the practice of extended half-tier lockdowns, discussed above. When inmates are confined to their cells for extended periods, they have limited access to custody staff and can be denied access to medical and mental health care. For example, inmate Chester H. reported that he had a seizure during the 26-hour lock down period and he was unable to receive medical care and was unable to attract the attention of CCJ personnel. He needlessly suffered while he waited for medical care. Because the nurses do not go onto the units to deliver medications to inmates who are locked in their cells, inmates who are on lockdown status during medication administration do not receive their prescribed medications. The

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extended lockdowns interfere with implementation of prescribed treatment plans and continuity of care for inmates.

11. Inadequate Medical Facilities

Medical facilities at CCJ lack adequate space, privacy, lighting, and sanitation to provide inmates with medical care consistent with generally accepted correctional standards. Approximately 300 inmates receive face-to-face medical care daily.

Inadequate space is especially significant because it limits CCJ's ability to provide medical services such as intake screenings, sick calls, and health assessments as well as care for inmates with specialty, chronic, and acute needs. The RCDC intake area is inadequately equipped to manage the daily volume of inmates during the essential intake screening process. The area is constantly congested and overcrowded.

Generally accepted professional standards of correctional

medical care require that for a proper clinical evaluation

inmates be examined in a clean and private setting with

sufficient lighting and access to necessary diagnostic tools. We

found mouse droppi~gs in dispensaries and medication rooms

throughout the facility.

Moreover, some of these rooms lacked

accessible hand-washing sinks or disinfectant, and contained

unsecured syringes and other sharp implements, which can be

potentially dangerous. Further, the floors and work surfaces of

all of the medical units and intake screening area were filthy.

12. Inadequate Dental Care

CCJ fails to provide adequate dental care to its inmates. Dental care is an important component of overall inmate health care. Poor oral health has been linked to numerous systemic diseases. Contrary to generally accepted correctional standards, dental care at CCJ is not timely and does not include immediate access for painful or urgent conditions. During our June 2007 on-site visit, we found that there was only one dentist responsible for over 9,500 inmates. 47 We further learned that the dentist was unable to perform any restorative care. The dentist's services were limited to extractions and it usually takes about two weeks before the dentist was able to perform any necessary follow-up care. More.alarming, we learned that over 25

47 Three dentists, one dental hygienist, and seven fulltime equivalent dental assistants were cut in February 2007.

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percent of the extractions performed at CCJ resulted in chronic infections such as osteitis (inflammation/disease of the bone) or dry sockets.
We also found that the dentist typically was unable to treat inmates with serious or urgent dental needs. We found many instances where inmates complained of tooth abscesses, but the dentist was unavailable to treat their serious dental needs. For example, inmate Derek B. was admitted to CCJ on June 17, 2007, with a tooth abscess. Although Derek requested dental care, the CCJ dentist did not provide treatment for his tooth abscess. Without proper treatment, nerek is at risk of serious deep tissue infection, pneumonia, sepsis, septic shock, and possibly death.
As a ~~sult of the dentist's inability to treat serious dental needs, the Cermak emergency room and sick call are inundated with dental emergencies. Despite having Cermak physicians treat these serious dental emergencies, inmates continue to suffer needlessly because they do not receive appropriate follow-up care.
13. Inadequate Quality Assurance and Perfor.mance Measurement
CCJ fails to engage in consistent, effective quality assurance reviews in order to monitor and assess the quality of medical care offered at the facility. An adequate quality assurance and performance measurement instrument is necessary to examine the effectiveness of health care delivered at CCJ, to discuss medical care results, and to implement corrective action so that the quality of care is improved. During our on-site visits, we found that CCJ had discontinued many of its performance measurements in February 2007 because CCJ lost accreditation by the National Commission on Correctional Health Care. As a result, CCJ discontinued its review of chronic disease care, acute and chronic care, completion of treatment for STDs, and access to care. Performance measurements are a critical component to ensure that polices and procedures are in place and to ensure adequate care. Without performance measures, the quality of medical care will suffer.
We also found that CCJ failed to conduct self-critical mortality reviews. Our expert reviewed mortality reviews and autopsies of 13 inmates who died while in custody at CCJ and found that none of the mortality reviews were self-critical. The absence of self-critical review creates a barrier for proper review that will ensure that proper policies and procedures are in place to correct failures and ensure adequate care, prospectively.

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Finally, staff involved in the inmate grievance process are frustrated that once a medical or mental health related grievance is referred to Cermak, a response is not forthcoming. The inmate grievance system should alert medical staff to possible weaknesses in the provision of medical care. We reviewed numerous grievance files that alleged the need for medical services, some of an emergent nature, that showed a referral to Cermak, but contained no actual response to the grievance. For example, inmate Steve S. filed a grievance on March 19, 2007 alleging that he was taken off his psychotropic medication without seeing a doctor, that he had been experiencing nightmares that prevented him from sleeping at night, that he was hearing voices, and that he was contemplating taking his own life and desperately needed help. The CRW acknowledged receipt of the grievance on March 23, 2007, but did not mark the grievance as an emergency and referred the grievance to Cermak with a statement that Steve S. merely alleged he was not getting proper medical attention. On April 2, 2007, Steve S. received a response stating, ~Referred to Mental Health Services." The grievance file does not contain any information, indicating whether Steve S. ever received mental health treatment.
C. INADEQUATE MENTAL HEALTH CARE
CCJ fails to provide inmates with adequate mental health care that complies with constitutional standards. CCJ fails to address the specific needs of inmates with mental illness, including: (1) failure to timely and appropriately evaluate inmates for treatment; (2) inadequate assessment and treatment; (3) inadequate psychotherapeutic medication administration; and (4) inadequate suicide prevention.
Mental health services at CCJ are provided through a combination of County Cermak employees and a contract with the Isaac Ray Center (~IRC") for psychiatric services. Cermak mental health services are directed by a Chief Psychologist who supervises a staff of approximately 50 individuals, including two medical social workers, three activity therapists, one mental health specialist supervisor, and approximately 40 Mental Health Specialists (~MHSs"). County mental health services have recently experienced specific cuts in staffing. The result is an inadequate number of trained staff to provide adequate programming and coverage in the mental health areas.
1. Failure to Timely and Appropriately Evaluate Inmates
CCJ fails to properly identify inmates with mental illness through adequate screening. Adequate screening of incoming

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detainees for mental health care needs is instrumental to a facility's ability to identify inmates in need of mental health services, to provide appropriate mental health care, and to reduce potential harm to those whose conditions would otherwise go unrecognized. Mental health screening should comport with generally accepted correctional standards of care to aid in classification, identification of emergent mental health care needs, provision of continuous care, and management of medication.
Follow-up of known or new mental health problems is a key focus of intake screening. Mental health screening information should be incorporated into an inmate's medical record. This ensures the prompt continuation of necessary medication for all inmates with chronic or newly identified mental health conditions. Persons with potentially serious and/or chronic mental health illness (i.e., active psychosis, suicidal ideation) should be referred from screening for prompt mental health evaluations and examinations by a psychiatrist.
As indicated, CCJ's medical screening and follow-up care procedures deny necessary care to inmates. The policy governing the CCJ mental health screening process is completely inadequate. Insufficiently trained MHSs perform mental health initial intake· screening at CCJ. This screening is not accomplished under appropriate medical supervision. The system allows technicians, who are not adequately or appropriately trained in detecting mental illness, to query inmates and detainees regarding their mental health history.
For mental health screening, CCJ staff utilize a form entitled "Department of Mental Health Services Brief Primary Psychological Screening Tool" which is not then incorporated into the medical record. This is a one page form that is used to collect brief demographic information and answers to 11 .general questions. No mental status exam is completed at that time. At the end of this brief interview, which lasts for less than five minutes, the MHS·makes a decision whether to refer the inmate to general population, refer the inmate for admission to psychiatric services, or to conduct a secondary interview. The screeners do not ask questions beyond those on the form, and do not appear to understand when additional questions were indicated or what those questions might be, especially relating in the area of assessment of suicide risk. Thus, mental health symptomatology that is associated with past hospitalizations, current treatment, or suicidal ideation, is unlikely to be uncovered.

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Consequently, our expert consultant found that less than five percent of inmates screened are identified as having psychiatric problems. The County's Director of Psychiatric Services acknowledged that the screening process was flawed and one would expect the percentage of inmates identified with psychiatric problems to be as much as ten percent. No psychiatrists are assigned to supervise or support the RCDC intake area where the initial mental health screening is conducted. In addition, we found that even for those inmates who screen positively for serious mental illness, the subsequent referral process to mental health treatment providers is flawed.
2. Inadequate Assessment and Treatment
CCJ fails to appropriately assess and treat inmates with mental illness, including those inmates on the acute care units and in the RTU. Our investigation revealed two principal problems. The first is the lack of attention to past mental health treatment records including previous psychiatric hospitalizations. Virtually no collateral mental health care information is requested or utilized in the assessment process. The second problem is that medical information already collected is not available for review or utilization in the continued assessment and treatment process. Our review of records indicates that this leads to multiple, often conflicting diagnoses, potential over prescription of antipsychotic and antidepressant medications, and medication dose adjustments without clear rationale. These failures have resulted in mental health deterioration and unnecessary suffering.
We noted that there are significant problems with the mental health treatment records. CCJ fails to maintain complete, accurate, and systematically organized mental health treatment records. CCJ's medical and mental health records system is completely inadequate and mismanaged. We observed numerous incomplete, unfiled, and inaccurate records. This flawed record system greatly increases the risk of error in assessment, treatment, and care. The County Director of Psychiatric Services described the medical record operation within CCJ as ~grossly inadequate."
The following examples are illustrative of the assessment and treatment failures at CCJ:
a. Seth P. was seen for a psychiatric consult during our July 2007 on-site visit. Seth had been admitted to CCJ three to four weeks prior to the consult and, after initial screening, had been placed in the general

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population. No records were available or requested48 at the time of the consult. The psychiatrist evaluated Seth and assessed him as exhibiting grandiose thinking and hyperactivity, prescribed medications, and ordered Seth to be admitted to CCJ's acute psychiatric unit for further evaluation. Immediately following the psychiatric consult, Seth was sent to an outside emergency room for evaluation for a possible fracture of his right hand. Upon his return to CCJ, the intake MHS,49 who was not aware of the recent psychiatric assessment due to the inadequate record keeping, determined independently that Seth was to be admitted to the general population. The result was that Seth received no further psychiatric evaluation and did not receive the prescribed antipsychotic medication ordered by the psychiatrist. so
b. Melanie o. had a miscarriage at CCJ on May 25, 2007,
was depressed, and had not received any psychiatric follow-up even though she was taking psychotropic medications. During our June 2007 on-site visit, we observed Melanie sitting in a hallway, having what proved to be an acute allergic reaction. No medical records for Melanie were available at that time. Eventually, Melanie's medical record was obtained and the record reflected that she had been sent to the emergency room two days earlier because of sYmptoms of allergic drug reaction. Medication was prescribed, but Melanie had not received the medication because there was no record of the prescription order from the hospital. No medical evaluation had been completed to
48 The Director of Psychiatric Services indicated that to request such records would be fruitless. When we insisted that the records be requested, none were available nor could they be located. Eventually Seth P.'s medical records were located, two days later, and the record was found to be incomplete.
49 Each time an inmate is transferred or leaves the facility for a consult, he is returned to the intake area for a housing classification. In this case, the housing classification was conducted by the intake MHS.
50 The psychiatrist was not aware of the mixup and the situation was rectified only after we brought the matter to his attention. The Director of Psychiatric Services indicated that this was typical of what happened at CCJ on a daily basis.

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determine the cause of her allergic reaction and no psychiatric assessment of her mental state occurred.

c. Kyle N., who had been assigned to CCJ's acute

psychiatric unit, had a medical record which contained

misfiled medical record information belonging to

another lnmate.

'

d. Anthony G. was housed on a Division IX segregation unit, with limited out-of-cell time, and had not had any access to psychiatric care in over six months. He reported setting fires to get access to medical and mental health care. The officers' log verified Anthony's fire setting.

e. Drew E. was also housed in Division IX and admitted that he also set fires to get access after ~epeatedly receiving no response to his grievances over lack of access to medical and mental health care.

As demonstrated, CCJ fails to provide essential, generally accepted components of an adequate treatment programs in a correctional mental health system. The crisis level of care lacks the capacity for necessary short-term treatment. There is not adequate physical space for evaluating and treating inmates in the emergency or RCDC areas. At present, psychiatrists do not go to the general population to see inmates or conduct clinics. In addition, psychiatrists do not make rounds in any segregation areas. Rather, all inmates are brought to the emergency room area to be seen. The result is that inmates who for security reasons or lack of escort correctional staff cannot be brought to the emergency room area, are not seen.

In addition, CCJ does not have access to an acute care program that would provide appropriate access for inpatient hospitalization. For example, mental health staff have no involvement in substance abuse assessment or treatment and make no referrals for substance abuse assessment or treatment. Also, a chronic care program for inmates with serious mental illnesses does not exist. While CCJ does provide segregated housing units for inmates with serious mental illnesses, these housing units lack an adequate treatment program, which is an essential component of an adequate chronic care program.

3. Inadequate Psychotropic Medication Administration

CCJ fails to timely and appropriately evaluate inmates for the administration of psychotropic medications and to monitor

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their continued administration. Many CCJ inmates require psychotropic medications to avoid the unnecessary suffering of acute and chronic episodes of mental illness. Generally accepted correctional, mental health care standards require that a physician see an inmate usually before, but clearly shortly after, a prescription for psychotropic medication is written in order to evaluate whether the medication should be maintained and to evaluate the continued administration for proper dosage and effectiveness. Inmates who remain untreated, or who are treated without being seen by a physician, may suffer from a worsening of their sYmptoms, including suicidal and homicidal thoughts, or from the potentially lethal side effects of medication. CCJ consistently fails to follow this practice.
We found significant problems with regard to medication management, which include the following: (1) delays ranging from days to weeks for inmates having their psychotropic medications started after their admission to CCJ; (2) breaks in receiving their medications after their prescriptions were initiated at CCJ related to housing changes and nurse unavailability for medication administration; (3) inmates not receiving their prescribed medications due to being locked down for extended periods of time and unable to receive medications when called; (4) numerous medication errors appeared to be common; (5) psychotropic medications 'being prescribed or reordered without any clear medical rationale or justification; and (6) lack of monitoring for side effects, or potential toxicity, particularly with regard to the psychotropic drugs Lithium, Depakote, and Clozaril.
As confirmed by our investigation and acknowledged by the Director of Psychiatry, inmates routinely do not receive medications as prescribed or have lapses in medication administration. Medication errors were common due to nurses being overwhelmed and failing to observe inmates taking their medications or to assure that the medication was delivered as prescribed.
Medication administration problems are compounded by the fact that psychiatrists do not utilize any formal practice guidelines or protocols with regard to the psychiatric care being provided at CCJ. No routine lab work, weights, measurements, or screenings are conducted regardless of the medication being prescribed. Generally accepted professional standards require regular blood draws and lab work whenever certain psychotropic drugs are prescribed to ensure that the patient is receiving therapeutic levels of the medication. Metabolic syndrome which is characterized by the presence of risk factors including

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obesity, abnormal lipid profiles (high LDL cholesterol, low LDL cholesterol, and high triglycerides) is not tracked. Screening for the side effects of antipsychotic medication is not routinely done. The result is that CCJ is providing medication management that significantly departs from generally accepted professional standards. Illustrative examples from 2007 include:
a. Salazar F. did not receive his antipsychotic medication after his transfer to Division IX from CCJ's acute psychiatric unit.
b. Although Raul G. was housed in the Division V medical unit, he did not receive his prescribed antipsychotic medications for three weeks after intake.
c. Julius T. was prescribed antipsychotic, antianxiety, and antidepressant medications. The rationale for prescribing these medications could not be determined. In fact, the psychiatric portion of his medical record concerning substance abuse, depression, anxiety, and withdrawal could not be located.
d. Jones C. was prescribed three varying doses of an antipsychotic medication without clarification as to which dosage was appropriate (40mg, 60 mg, or 80 mg) or clarifying changes in dosage, if that was the case. It appeared that CCJ clinicians were engaging in polypharmacy, the inappropriate practice of prescribing multiple medications within the same class, without justification, for the same illness. He was also being prescribed two additional antipsychotic medications with no justification in the record for the multiple medication orders. It is likely that the lack of available records contributed to the disorganization of the care of this inmate.
e. Arnold R. was being prescribed an antipsychotic medication and an antidepressant without any documentation in his medical record as to the rationale for the prescription or any follow-up on his psychiatric medications.
f. Diego F. was receiving two antipsychotic medications and an antidepressant medication. His record contained no rationale for the medications and identified him as having no psychiatric problems.

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4. Inadequate Suicide Prevention
Suicide prevention practices at CCJ are grossly inadequate. Constitutional requirements mandate the development of suicide prevention standards. These standards require (1) an appropriate policy and procedure; (2) education and training for all staff members; (3) appropriate screening to assess suicide risk; (4) appropriate housing for those identified as at risk; (5) appropriate supervision, observation, and monitoring of those inmates so identified; (6) appropriate referrals to mental health providers and facilities; (7) appropriate communication between correctional health care and correctional personnel; (8) appropriate intervention addressing procedures of how to handle a suicide in progress; and (9) appropriate notification, reporting, and review if a suicide does occur.
CCJ's current practice of suicide prevention does not comport with generally accepted professional standards of correctional mental health care. CCJ's written policy on suicide prevention fails to ensure appropriate management of suicidal inmates and lacks major components of an adequate suicide prevention program. For example, CCJ's policy states that "if a patient is determined to be an imminent risk of harm to self, they will be placed in restraints following protocol." This practice of manually restraining suicidal individuals is contrary to generally accepted professional standards and, as affirmed in conversations with CCJ staff, being utilized solely due to lack of staff for continuous observation of the suicidal inmate. The result of this inappropriate policy is the unnecessary and excessive use of restraints.
An illustrative example is inmate Dallas W. who was placed in four-point leather restraints (all limbs) after expressing thoughts of committing suicide, despite the fact that he exhibited no aggressive or suicidal behavior. The review of restraint logs from July 2006 to June 2007 showed that in over 50 percent of the episodes, inmates were shackled with full leather restraints because of suicidal ideation and the fact that continuous observation was unavailable. This is grossly inappropriate.
In addition, the appropriate observation of suicidal inmate patients is hindered by physical limitations of the rooms in which they are being placed. Observation rooms have blind spots and windows that are set too high for routine viewing. Moreover, many of the rooms contain numerous environmental risk factors including exposed plumbing and electrical hazards.

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Contrary to generally accepted correctional practices, CCJ correctional officers and other staff have no access to cut-down tools for quick response in the event of a suicide attempt by hanging. In each of the three CCJ suici,des completed in 2008, there was a delay between discovery of the inmate hanging and removal of the noose. For example, on January 1, 2008, the first correctional officer to discover inmate Grant N. hanging from his bunk attempted to lift Grant to remove the sheet from his neck, but was unable to do so. Approximately six additional minutes elapsed before paramedics were able to cut Grant down, using a key to sever the noose.
As a result of the administrative division between corrections and health care at CCJ, communication between mental health staff and correctional staff is informal and often strained. Significant communication problems between custody and mental health staff result in a fragmented, uncoordinated system. This problem is exacerbated because suicide prevention is notunder the direction and supervision of mental health staff. Inmates placed on suicide watch are being observed by correctional officers who have a myriad of other responsibilities in addition to the observation task and have limited or no familiarity with the on-going assessment of suicidal individuals. The current suicide prevention program fails to contain different levels of supervision of the inmate based on the presenting risk factors for suicide. Staff are not appropriately trained in suicide prevention. Annual training for correctional officers regarding suicide prevention is not required. Correctional officers assigned to the mental health units do not receive any additional specialized training on working with individuals with mental illness. Finally, contrary to generally accepted practice, there is no adequate clinical administrative review by mental health staff following a suicide or a suicide attempt to identify what could have been done to prevent the act. Our review of the records of two recent inmate suicides51 illustrates the significant problems:
a. On July 27, 2006, inmate Manuel M. hanged himself to death in a maximum security wing of CCJ. A correctional officer reportedly found Manuel hanging from a bed sheet at 3:20 a.m. He had been in CCJ
51 In addition to the suicides discussed above, on March 14, 2008, an inmate was found hanging in his Division I cell. He was hospitalized in critical condition and died when he was taken off life support on March 18, 2008. On April 14, 2008, another CCJ inmate hanged himself with a bed sheet in a Division I cell, and was pronounced dead at the hospital.

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approximately one week on a charge of failing to register as a sex offender. His records reveal that at intake he provided a history of suicide attempts in the past r but denied current suicidal ideation. No secondary mental health evaluation was conducted. Manuel received no additional mental health assessment prior to his death in the facility.
b. On July 25 r 2006 r inmate Andrew K. committed suicide by hanging himself in his cellr two days after arriving at CCJ. Andrew was discovered by another inmate. His record reveals that at the time of intake r Andrew denied suicidal ideation and no secondary mental health evaluation was conducted. Andrewrs documented past history included three prior psychiatric hospitalizations r including a suicide attempt by overdose. Nevertheless r Andrew received no additional mental health assessment prior to his death. No recommendations or findings were made in the mortality review r except for the comment ~May consider a two person accommodation to watch over each other."
5. Inadequate Staffing r Training, and Supervision
CCJrs fragmented system of providing mental health care has contributed to many of the problems above .. In addition r many of the shortcomings in mental health care are exacerbated by the lack .of adequate staffing r support r training r and supervision. 52 CCJ maintains an insufficient number of appropriately trained mental health and custody staff to provide adequate mental health services. 53 Moreover r delays in access to mental health care are exacerbated by an insufficient number of staff trained to identifYr respond r and provide the necessary mental health treatment. Generally accepted correctional standards of care
52 Concerns were raised by the Chief Executive Officer of the IRC regarding the decreased budget for mental health services and the resulting mental health staff cuts; particularly the decrease in. the number of MHSs and the replacement of existing MHSs with less qualified individuals. The severe budget cutbacks r as reflected in decreased staffing r resulted in a ~breakdown in translation and execution of mental health care."
53 We observed very limited programming on the units. An interview with the Chief Psychologist verified that within the last six months due to budget cuts and the resulting staff reduction r programming on the units had been severely reduced.

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require that facilities maintain adequate staffing to provide inmates with necessary mental health care.
Shortages in key staff areas (MHS, correctional staff, nursing, medical records, and social workers) interfere with adequate access to mental services. 54 As indicated, there is an inadequate number of MHSs to provide screening and supportive mental health care. This problem is compounded by the fact that recently hired MHSs lack the necessary training and experience. As indicated, correctional staff are inadequately trained to work with mental health inmates. In addition, officers are being rotated too frequently to develop familiarity with the population. 55 There are an insufficient number of nurses to provide mental health services for the designated mental health units and to run a medication administration program that comports with generally accepted professional standards. 56 In addition, there are insufficient numbers of social workers to provide for discharge planning, continuity of care, and
54 These staffing shortages were noted by the Court Monitor for Mental Health responsible for monitoring compliance with the CCJ consent decree in Harrington v. DeVito, No. 74-C-3290 (N.D. Ill. Oct. 19, 1978). In his 1998 and 2002 reports, the Court Monitor for Mental Health found that a shortage of adequately trained nurses, activity therapists, mental health specialists, psychiatrists and psychologists resulted in inmates "facing significant access barriers to care and adequate therapeutic programming resources." He further found that the lack of adequate numbers of medical record technicians resulted in incomplete records, included filing not being completed in a timely fashion or misfiling, and lack of availability of records during clinical assessments. Our independent evaluation identified that inadequate staffing currently results in unconstitutional mental health care deficiencies. These same staffing deficiencies were identified by the Harrington lawsuit and referenced in the 1998 and 2002 Court Monitor for Mental Health's reports.
55 The Court Monitor for Mental Health also noted the lack of compliance with the Harrington Consent Decree with regard to security staffing. He found that the failure to utilize appropriately trained correctional officers on a regular basis in mental health areas was noted to have significantly impacted the treatment offered to inmates with serious mental illness.
56 This was acknowledged by the Acting Director of Nursing who indicated it is difficult to maintain adequate psychiatric nurse coverage on the psychiatric units.

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reintegration into the community. Finally, there are an inadequate number of trained health record technicians to operate an effective health record system.
D. INADEQUATE FIRE SAFETY
The level of fire safety at CCJ is poor. Inadequate fire safety at any correctional institute presents a grave risk of harm from smoke, fire, and the serious security concerns that arise during an emergency. These serious risks are present throughout CCJ. There are no smoke detectors in most inmate housing areas, which means staff have no way to receive warning of fire or smoke other than from the inmates who may have set the fire. Keys are not marked for rapid identification in an emergency. Staff was often not prepared to quickly unlock the doors for rapid evacuation, not knowledgeable of how the fire alarm system works, and poorly prepared for an emergency. Weekly Divisional Reports, from February 26, 2007 through June 17, 2007, show an average of 1.8 fires per week at CCJ. During our site visits, we saw evidence in numerous cells that inmates are setting fires beneath their beds in order to utilize the metal bunk as a hot plate to heat food. Multiple inmates reported that they resort to lighting fires in their cells in order to get correctional officers' attention. Considerable improvement in built-in protection and staff preparedness is necessary to meet generally accepted standards for fire safety in a correctional setting. 57
One CCJ correctional officer is assigned to make monthly fire safety "inspections" for the entire facility. These are cursory inspections to confirm that items on a standard checklist are done. The designated o~ficer has not had training in fire safety and apparently just fills out the inspection check list with little in-depth evaluation of safety issues. Reportedly, there is a fire safety officer for each division, but these officers' only responsibility regarding fire safety is the monthly inspection of fire extinguishers. Fire safety inspections should be done by persons trained in fire safety. They should have knowledge in basic housekeeping, emergency preparedness, basic applicable codes, fire extinguishers, and sprinklers.
57 In addition to generally accepted correctional standards, the Illinois Office of the State Fire Marshal requires that all jails must comply with the National Fire Protection Association's Life Safety Code ("LSC") (200).

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Key control is a major problem. On several occasions during our on-site visits, when officers were asked to unlock doors, there was confusion as to which key unlocked a specific door or if the correct key was on the ring the officer carried. In many cases, several keys were tried without success, and then a key on the same ring was found that would unlock the door. The keys were not identified by touch and the visual markings were difficult to read in low light situations. In a correctional setting, generally accepted correctional standards require that all emergency keys be identified by sight and touch. 58 On October 5, 2007, the Sheriff's Office reported that CCJ had made improvements in key control, but we have not yet verified this information.
Divisional emergency procedures and fire plans are different between divisions with no standard format or standard procedures. For example, the Division IV instructions require that emergency keys to be color-coded red, but other divisions do not. Some instructions include floor plans, while others do not. While it is understandable that both the physical plants and levels of security differ by division and require some variation, the general format and information should be similar. This will help employees to more easily familiarize themselves with the procedures as they move positions.
Fire drills are not being done on a regular basis on each shift. Many officers reported that they had not participated in any recent fire drills 'and had not had training on fire safety since the academy. According to generally accepted correctional standards, monthly fire drills are required in institutional occupancies. 59 Monthly drills should rotate so that they are conducted quarterly on each shift. Drills should be conducted at differing times and under differing conditions, such as using different egress routes to confirm that officers. have the necessary keys and know how to use them. Records of .each drill should be maintained for at least one year.
CCJ does not have sufficient smoke detection and sprinkler systems. Smoke detection should be installed in all housing units in accordance with generally accepted correctional

58

See also LSC § 23.7.5.

59

The Municipal Code of Chicago, Fire Prevention Code

(~FPC"), also requires monthly fire drills. FPC, Article XVI,

§ 1 (15-4-920) (Jan. 1999).

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standards. 60 Basement storage areas should have sprinkler protection or be enclosed in fire resistive construction. 61 Stairs should be enclosed so that smoke will not travel throughout the buildings. Most of the CCJ Divisions do not comply with these generally accepted correctional standards. For example, Division I, which was built in 1929, has no sprinklers and no smoke detection. A manual fire alarm system is installed. The cells are open-barred in the front and back and the doors to the stairs are open bars from the basement to the fourth floor, which could allow smoke to spread quickly throughout the building in the event of a fire. Only Division XI, Dorm 4 of Division II, and Cermak are fully protected with automatic sprinklers. Some of the buildings have partial sprinkler protection in selected areas of the basements, while others do not. Several fire/smoke barrier doors were not working properly. Many of the stairwell and fire doors throughout CCJ were wedged open, which would allow smoke and heat to travel quickly throughout the building. In addition, in many divisions no one is consistently checking emergency doors and locks to ensure that they are operational. We found that the locking mechanisms on multiple emergency exits in housing units had been sabotaged by inmates ~nserting debris into the lock, unbeknownst to staff, which prevented the doors from opening from inside the housing unit. This is a major safety hazard.
In many divisions, we found extra mattresses stored inappropriately in rooms without adequate fire protection. For example, in Dormitory Two of Division II, we found several mattresses stored in the multi-purpose room on the first floor, which is not designed or protected as a storage room. A fire in these mattresses could quickly spread smoke throughout the building and unnecessarily expose inmates to danger. Mattresses should only be stored in designated areas that are protected against fire risks. The potential risk from CCJ's flammable mattresses is clear. On January 4, 2007, two officers were injured after an inmate in Division IX set his mattress on fire. One officer suffered smoke inhalation and was admitted to the hospital. Another officer was cut on his arm during an evacuation of the housing unit.
Finally, as discussed above, the RCDC becomes very crowded in the late afternoons and evenings. There are two doors out of this area. Assuming each door has a clear width of 34 inches,

60

See also LSC § 23.3.4.4.

61

See also FPC § 9 (15-i6-030) (b); LSC § 23.3.2.

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generally accepted correctional practices indicate that each door is a sufficient exit for a crowd of 135 to 170 persons. 62 That means the RCDC can safely provide emergency exits for 270-340 people. The number of RCDC occupants, including newly admitted inmates, inmates returning from court, correctional officers, and medical and mental health care staff, often swells well beyond 400 persons, clearly exceeding the available egress capacity.
E. INADEQUATE SANITATION AND ENVIRONMENTAL CONDITIONS
CCJ has severe environmental health and safety problems at every level of operation. 63 Most CCJ staff appeared well meaning with regard to environmental conditions, even when, in some instances, the staff person had never received adequate training to sufficiently understand the task at hand. However, inadequate staffing, inadequate training, insufficient oversight, and a lack of uniformity of policies and procedures across divisional lines are detrimental to staff who want to perform at a professional level.
1. Facility Maintenance
In a facility the size and age of CCJ, it is normal and expected that maintenance and repair work would be an on-going challenge. In a correctional setting where inmates and staff are dependent on maintenance staff for their water, heat, lighting, and ventilation, it is also expected that these issues would be addressed in a timely manner in order to reduce risks of illness and injury to inmates and staff alike. That is not the case at CCJ. Work orders generated by correctional staff are transmitted to the Cook County Facilities Management Department. During our site visits, we observed hundreds of maintenance and repair needs, many of which had not been addressed for months. Upon review of work orders generated between February and July 2007, we found 2715 were uncompleted, including many that were more than four months old. With the exception of Division XI, staff uniformly complained about the lack of timely responses to work order requests. The failure to timely process work orders exacerbates the overcrowding issues at CCJ. In Division Valone, more than 100 cells (approximately ten percent of the division's
62 See, e.g., LSC § 7.3; FPC § 10 (13-160-210).
63 Although the John Howard Association found "reasonably successful" sanitation efforts in 2007 (Court Monitoring Report at 64), conditions at CCJ were far below compliance with constitutional requirements during our on-site visits.

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capacity) were closed because of maintenance issues during our July 2007 visit.
Part of the backlog regarding work orders is a re~ult of the division between CCJ's correctional staff and the County Facilities Management Department. Correctional staff are not permitted to undertake any facility repair work. Even a burned out lightbulb in an inmate's cell requires a Facilities Management work order and an electrician to change the bulb. This results in inmates having no lighting in their cells for multiple days in a row, which is especially dangerous when the inmates are locked inside their cells for extended periods.
Electrical hazards were prominent throughout the housing areas and neither correctional officers nor maintenance staff seemed to be concerned about them. During our July 2007 on-site visit, 34 uncompleted work orders for exposed wiring in Division XI dated as far back as February 23, 2007. We frequently observed broken switch plate and receptacle covers with exposed live wires throughout the housing units, including shower and toilet areas where floors were wet, creating a severe shock hazard. In Division VIII, a receptacle in a recreation room was pulled completely away from the wall, with no cover plate. The outlet tested live, which is a major safety hazard to inmates and staff.
Plumbing deficiencies were also abundant. It was common to find that multiple sinks, toilets, and showers were inoperable in a single tier. It was rare to find hot water availability in a cell, and we observed many inmates locked in cells for as long as 26 hours with no access to drinking water. We saw multiple incell plumbing leaks that resulted in constant cell flooding. Many of these conditions had existed for more than a month.
Serious ventilation issues were observed in some areas. In Division VI, Unit 2-C, 21 out of 22 cells had no ventilation because metal plates had been installed behind the grate on the supply ducts, prohibiting the movement of air into the cells. 64 Although the unit was designed to house 44 inmates, it was overpopulated at the time of our visit and housed more than 60 inmates, with many inmates housed three to a cell and locked in for 26-hour periods every other day. These cells are not big enough to meet generally accepted correctional standards for

64

This condition violated Illinois County Jail Standards

701.120 (a) (4) .

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three inmates. 65 Air quality measurements indicated excessive temperature and relative humidity within the tier. The combination of high temperature and humidity, overcrowding, and lack of air movement creates an unhealthy environment that increases the risk of disease transmission. This particular tier also had exposed wiring in the dayroom; all three of the sinks in the toilet area were out of order; two of the three showers were inoperable; a water leak under the tile on both sides of the bathroom door created a falling hazard; and six burned out lights in the dayroom resulted in unacceptably low light levels.
Finally, as discussed above, conditions in the RCDC intake area are grossly inadequate for the purpose it serves and the number of inmates who are processed through the area each day. Consistent with generally accepted correctional standards, the limited toilets available should serve a dormitory of a maximum of 36 inmates, not the several hundred inmates processed through the RCDC each day. Given the lack of timely responses to plumbing problems at CCJ, it is easy to imagine the filthy environmental conditions that exist in the RCDC when the toilets become clogged.
Maintenance and sanitation are categorically inadequate throughout the facility, exposing inmates and staff to unhealthy and unsafe 'environments as a result.
2. Pest Control
The three major pest problems observed during our site visits involved mice, cockroaches and drain flies. Although mice and cockroaches are nocturnal by nature and are not generally seen in daylight hours, we did observe a few of these during our visits and found evidence of their presence. Staff and inmates alike commented on the presence of mice in the facility and many
65 None of the cells at CCJ are sized to accommodate more than two inmates per cell. In fact, the American Correctional Association waived their sizing standards for portions of the facility to allow accreditation because many of the cells do not meet current standards for housing two inmates. A third inmate in these cells has to place his mattress on the floor of the cell, further reducing the unencumbered space in the cell and making it difficult for the inmates to move around in the cell. The third inmate on the floor is forced to sleep with his face at floor level where he inhales dust particles and airborne allergens that settle to the floor; increasing the risk to the inmate of contracting respiratory infections.

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inmates had towels or other types of barriers across the bottom of their celldoors to keep the mice out of their cells at night. Drain flies are small flies that are found in shower and toilet areas where they lay their eggs in gelatinous organic matter that builds up under the rim of toilets and in floor drains. These flies were noted in several of the divisions including the Cermak medical area where fly traps were being used to capture adult flies. Outbreaks of adult flies have been associated with bronchial asthma in susceptible individuals. Their presence is also a sign of inadequate housekeeping and sanitation.
Except for the food service and Cermak hospital areas, pest control is managed by CCJ staff. CCJ has only one person assigned to conduct pest control for the entire 96-acre facility. While this person is a licensed and certified pest control operator ("PCO"), one person cannot perform adequate pest control for a facility of this size and nature. Staff indicated that the PCO works on an on-call basis to resolve acute problems. Pest control at CCJ is totally a reactive effort. The size of the facility does not allow the PCO to do much follow up or preventive work. We found numerous mousetraps that had heavy layers of dust on them, indicating that little follow up work was done to check the traps and to replace bait as needed.
3. Sanitation Oversight
We were informed that CCJ has a single registered sanitarian on staff. However, upon interviewing the facility's sanitarian, we learned that she was not registered by any state or national professional organization and had no formal education as a sanitarian. She has been in her current position for six years, but has never had an opportunity for any in-service training outside of the department. She also had not had any opportunities for training on the few pieces of sanitation equipment provided to her. This lack of training severely limits her ability for professional growth to learn about current environmental health practice as well as emerging environmental issues in correctional facilities such as MRSA. The CCJ sanitarian is not being supported through training and education.
CCJ's sanitarian functions as an inspector who also provides some training to staff on chemical usage. Her inspections duties cover areas such as housekeeping, lighting, plumbing, chemicals, pest control, fire extinguishers, hot water temperatures, and the like. Housekeeping inspections are done by visiting one tier per division per month. Given the facility's size, it could be six months to a year before she is able to make a return visit to a particular tier. She checks hot water temperatures by asking the

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inmates because she has no tools to measure the temperature. She checks fire drill logs and the inspection tags on the fire extinguishers to make sure documentation is completed t but she has no involvement in the actual fire drills themselves. She checks lighting by looking for burned out fixtures because she has had no training on how to use a light meter. She inspects the kitchen but has no equipment to test or measure anything with to insure that safe food conditions exist in the kitchen. Her last ServSafe© and Illinois Department of Public Health Food Service Certification training occurred in 2001 and expired in 2006. Despite all of the inspection work she does t she has no authority to effect changes in housekeeping practices t food service operations t housing conditions t pest problems t or fire safety issues. In effect t she is an inspector of documentation more than a verifier of actual conditions at CCJ.
Organizational oversight appears to be weak throughout the divisions. We constantly observed conditions that should not have existed if staff were being held accountable for conditions in the housing areas. Staff must be aware of and take action when policies are violated by inmates and unsafe conditions are seen. Staff frequently seemed to turn their back on issues such as obvious safety hazards caused by inmates tampering with electrical outlets t hanging clothes lines from damaged light fixtures in cells or in shower areas t the accumulation of large amounts of commissary items and/or food items in their cells t etc. Apparently no one is held accountable for the poor levels of housekeeping that we observed throughout the jail.
Oversight must also extend to the inmates themselves. They must be held accountable for their actions when they do not adequately clean their cells and dayrooms t when they damage CCJ propertYt and when they openly violate CCJ policies. Failure to enforce inmate accountability greatly increases the maintenance load on staff and creates a higher risk for staff and inmate injuries.
4. Housekeeping
The level of cleanliness at CCJ is very poor. In the housing and medical areas we observed accumulations of dirt t trash t mold t and mildew that had been allowed to exist for long periods of time. Cells frequently had heavy layers of dirt and dust under the bunks and around the toilet areas. Shower areas frequently had dirt t mold t and mildew on walls and ceilings. Toilet areas were extremely unsanitary.

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Mattresses are not cleaned and sanitized between uses. Hundreds of mattresses.were seen in use that were worn to the point that they were incapable of being cleaned and many covers were missing entirely. Torn and damaged mattresses allow the transfer of harmful pathogens, such as MRSA, from person to person and also serve as convenient hiding places for shanks and other contraband.
5. Food Service
The food service program at CCJ is contracted to the Aram~rk Corporation, which operates two kitchens, one located in the basement of Division XI and a larger, central kitchen. The kitchens operate under a Health Analysis Critical Control Point process that is approved by the Chicago Department of Health. The food service supervisors currently have ServSafe© and Illinois Department of Public Health Food Service Manager Certifications. They receive outside inspections once or twice a year from the Cook County Department of Public Health and are inspected on a weekly and monthly basis by jail personnel.
The Division XI kitchen prepares approximately 4500 meals per day and operates three shifts per day seven days per week. While sanitation was problematic during our June 2007 visit, the Division XI Superintendent took immediate action and conditions were vastly improved during our July 2007 visit. However., as both of the dishwashing machines in this kitchen had been out of order since March 2007, so all pots, pans, and preparatory utensils are washed by hand without adequate sanitization procedures.
The central kitchen prepares approximately 30,000 meals per day and works 200 inmates per day in four crews. Although the County selects the inmates who work in the food service area, Aramark is responsible for their training and supervision. Inmate workers reported that they receive no training prior to working in the kitchen. Aramark staff confirmed that no formal training takes place. The correctional officers who work in the kitchen are responsible only for security.
In March 2007, CCJ found that inmate workers were not utilizing gloves or hairnets, numerous sinks had clogged drains, and excessive garbage was piled on the floor. During our on-site visits, the dishwashing machines had a very heavy scale buildup from hard water deposits that tend to clog spray nozzles and limit the effectiveness and proper washing of food contact surfaces. The floor in the dishwashing area is in poor repair, causing standing water, and is not easily cleanable as required

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by food codes. The Cook County Department of Public Health cited CCJ on March 13, 2007 for this violation.
The delivery of food to the housing areas is accomplished with non-insulated carts that are loaded from the plating line and held until they are picked up by the staff who are responsible for the delivery. The kitchen supervisor estimated that some carts are held two to three hours between plating and delivery. Because these carts are not insulated or heated, food is allowed to cool to a point at which bacterial growth can occur. Additionally, food was observed being plated at unacceptable temperatures. Food codes require that hot food be held and served at 140 degrees, but we observed food being plated for delivery at 26 to 44 degrees below the required temperatures. The low plating temperatures and significant delays in food delivery greatly increase the risk of food borne disease.
IV. REMEDIAL MEASURES
In order to rectify the identified deficiencies and protect the constitutional rights of inmates confined at CCJ, this facility should implement, at a minimum, the following remedial measures:
A. Protection from Harm
1. Use of Force
a. Develop and maintain comprehensive and contemporary policies and procedures regarding permissible use of force.
(1) Prohibit the use of force as a response to verbal insults or inmate threats.
(2) Prohibit the 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 CCJ has attempted a hierarchy of nonphysical alternatives which are documented.
(3) Prohibit the use of force as punishment.
b. Establish effective oversight of the use of force.

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(1) Develop and implement a policy to ensure that staff adequately and promptly reports all uses of force.
(2) Ensure that management review of incident reports t use of force reports t and inmate grievances alleging excessive or inappropriate uses of force includes a timely review of medical records of inmate injuries as reported by medical professionals.
(3) Ensure that incident reports t use of force reports and inmate grievances are screened for allegations of staff misconduct and t if the incident ,or allegation meets established criteria t that it is referred for investigation.
(4) Develop and maintain comprehensive policies t procedures t and practices for the timely and thorough investigation of alleged staff misconduct.
(5) Develop and implement policies and procedures for the effective and accurate maintenance t inventory and assignment of chemical and other security equipment.
(6) Develop and implement a process to track all incidents of use of force that at a minimum includes the following information: the inmate(s) name t housing assignment t date and type of incident t injuries (if applicable) t if medical care is provided t primary and secondary staff directly involved t reviewing supervisor t external reviews and results (if applicable)t remedy taken (if appropriate) t and administrative sign-off.
c. Develop an effective and comprehensive training program in the appropriate use of force.
(1) Ensure that staff receive adequate competency-based training in CCJts use of force policies and procedures.

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(2) Ensure that staff receive adequate competency-based training in use of force and defensive tactics.
(3) Ensure that lAD management and staff receive adequate competency-based training in conducting investigations of use of force allegations.
2. Safety and Supervision
a. Ensure that correctional officer staffing and supervision levels are appropriate to adequately supervise inmates. Discontinue the practice of cross-watching.
b. Ensure that inmate work areas are adequately -'-. supervised whenever inmates are present.
c. Ensure frequent, irregularly timed, and documented security rounds by correctional officers inside each housing unit.
d. Develop and implement policies and procedures requiring all tools, utensils, equipment, flammable materials, etc. are inventoried and locked down at all times.
e. Ensure that staff adequately and promptly report incidents.
f. Develop a process to track all serious incidents that captures all relevant information, including: location, any injuries,if medical care is provided, primary and secondary staff involved, reviewing supervisor, external reviews and results (if applicable), remedy taken (if appropriate), and administrative sign-off.
g. Establish a procedure to ensure that inmates do not possess or have access to contraband. Conduct regular inspections of cells and common areas of the housing units for contraband.
h. Ensure that inmates placed in lock down status are provided with appropriate due process that has been developed and implemented in policies and procedures.

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i. Increase use of overhead recording security cameras throughout the common areas of the facility.
j. Conduct regular inspections of cells and common areas of the housing units to identify and prevent rule violations by inmates.
k. Review, and revise as applicable, all security policies and Standard Operating Procedures ("SOPs") on an annual basis.
1. Review, and revise as applicable, all security ~ost orders regularly.
m. Revise policies, SOPs, and post orders for all armed posts to include instruction on use of deadly force and when and under what circumstances the weapon should be used.
n. To the extent possible, taking in account the different security levels and different physical layouts in the various divisions, standardize security policies, procedures, staffing reports, and post analysis reports across the divisions.
o. Provide formal training on division-specific post orders each time. a correctional officer is transferred from one division to another.
p. Implement specialized training for officers assigned to special management units, which include the Special Incarceration Units, disciplinary segregation, and protective custody units. Officers assigned to these units should possess a higher level of experience and be regularly assigned to these units for stability purposes.
3. Disciplinary Process
a. Ensure that inmates are afforded due process for any disciplinary actions against them, including promptly receiving a disciplinary ticket and a fair hearing.

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b. Ensure that disciplinary hearings are conducted in a private setting.
4. Classification
a. Develop and impl~ment policies and procedures for an objective classification system that separates inmates in housing units by classification levels.
b . . Update facility communication practices to provide officers involved in the classification process, with current information as to cell availability on each division.
c. Update the classification system to include information on each inmate's history with the Special Incarceration Unit "level system" at CCJ.
d. Provide competency-based training and access to all supervisors on the full capabilities of the CCJ classification and inmate tracking system (or any replacement system)
5. Inmate Grievance Procedure
a. Develop and implement policies and procedures to ensure inmates have access to an adequate grievance process that ensures that grievances are processed and legitimate grievances addressed and remedied in a timely manner, responses are documented and communicated to inmates, inmates need not confront staff prior to filing grievances about them, and inmates may file grievances confidentially.
b. Ensure that grievance forms are available on all units and are available in Spanish.
c. Ensure that inmate grievances are screened for allegations of staff misconduct and, if the incident or allegation meets established criteria, referred for investigation.
6. Access to Information
a. Ensure that newly admitted inmates receive information they need to comply with facility rules and regulations, be protected from harm,

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report misconduct, access medical and mental health care, and seek redress of grievances.
b. Ensure that inmates who are not literate are afforded the opportunity to have information on facility rules and services explained to them orally.
c. Ensure that information on facility rules and services is available in Spanish.
B. Medical Care
1. Intake Screening
a. Ensure that adequate intake screening and health assessments are provided. Develop and implement an appropriate medical intake screening instrument that identifies observable and non-observable medical needs, including infectious diseases, and ensure timely access to a physician when presenting symptoms require such care.
b. Ensure that acute and chronic health needs of inmates are identified in order to provide adequate medical care.
c. Ensure that medical screening information is reviewed in a timely manner by trained medical care providers.
d. Provide adequate screening and health assessments for inmates in accordance with generally accepted correctional standards of care and ensure adequate evaluation for mental illness and suicide risk.
e. Ensure that tuberculosis (~TB") screening is conducted in a timely manner.
2. Acute care
a. Provide timely medical appointments and follow-up medical treatment. Ensure that inmates receive treatment that adequately address their serious medical needs. Ensure that inmates receive acute care in a timely and appropriate manner.

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b. Provide adequate acute care for inmates with serious and life-threatening conditions.
c. Ensure that staff are adequately trained and prepared to handle emergent situations in accordance generally accepted professional standards.
3. Chronic care
a. Ensure that inmates receive thorough assessments for, and monitoring of, their chronic illness. Develop clinical practice guidelines for inmates with chronic and communicable diseases. Ensure that standard diagnostic tools are employed to administer the appropriate preventative care in a timely manner.
b. Adopt and implement appropriate clinical guidelines for chronic diseases such as HIV, hypertension, diabetes, asthma, and elevated blood lipids, and policies and procedures on, inter alia, timeliness of access to medical care, continuity of medication, infection control, medicine dispensing, intoxication/detoxification, record-keeping, disease prevention, and special needs.
c. Ensure that medical staff are adequately trained to identify inmates in need of immediate or chronic care, and provide timely treatment or referrals for such inmates.
d. 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.
e. Ensure adequate follow-up treatment and medication administration concerning all inmates with chronic conditions.

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4. Treatment and Management of Communicable Disease
a. Provide adequate treatment and management of communicable diseases r including TB and Methicillin-resistant Staphylococcus aureus ( "MRSAII ) •
b. Ensure that inmates with communicable diseases are appropriately screenedr isolatedr and treated.
c. Ensure that inmate and staff do not interfere with HVAC and negative pressure systems.
d. Develop and implement an adequate TB control plan in accordance with generally accepted correctional standards of care. Such should provide guidelines for identificationr treatment r and containment to prevent transmission of TB to staff or inmates.
e. Develop and implement policies that adequately manage contagious skin infections. Develop a skin infection control plan to set expectations and provide a work plan for the prevention of transmission of skin infections r including drug-resistant infections to staff and other inmates.
f. Conduct a sufficient initial health assessment r including screening for TB and STDs r of all inmates in a timely fashion.
g. Develop and implement adequate guidelines to ensure that inmates receive appropriate wound care.
5. Access to Health Care
a. Ensure inmates have adequate access to health care.
b. Ensure that the medical request process for inmates is adequate and provides inmates with adequate access to medical care. This process should include logging r tracking r and timely responses by medical staff.
c. Develop and implement an effective system for triaging medical requests. Ensure that sick call

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requests are appropriately triaged based up the seriousness of the medical issue.
6. Follow-Up Care
a. Provide adequate care and maintain appropriate records for inmates following hospitalization. Ensure that inmates who receive specialty or hospital care are evaluated upon their return to the facility and that, at a minimum, discharge instructions are noted and appropriately provided.
7. Record Keeping
a. Ensure that medical records are adequate to assist in providing and managing the medical care needs of inmates at CCJ.
b. Ensure that medical records are complete, accurate, readily accessible, and systematically organized. All clinical encounters and reviews of inmates should be documented in the inmates' records.
8. . Medication Administration
a. Ensure that treatment and administration of medication to inmates is implemented in accordance with generally accepted professional standards of care.
b. Ensure that administration of medication is accurate and adequately documented. Develop policies and procedures for the accurate administration of medication and maintenance of medication records. Provide a systematic review of the use of medication to ensure that each inmate's prescribed regimen continues to be appropriate and effective for his condition.
c. Ensure that medicine distribution is hygienic and appropriate for the needs of inmates.
9. Medical Facilities
a. Ensure that sufficient space is available to provide inmates with adequate medical care services including: intake screening, sick call,

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physical assessment, and acute, chronic, emergency, and speciality medical care (such as geriatric and pregnant inmates).
b. Ensure that medical areas are adequately clean and maintained, including installation of adequate lighting in medical exam rooms. Ensure that hand washing stations in medical areas are fully equipped, operational, and accessible.
10. Specialty Care
a. Ensure that specialty consultations are timely and that any resulting reports are forwarded to CCJ staff. Specialist recommendations should be implemented in a timely manner or, where deemed inappropriate, a CCJ physician should properly document why such recommendations were implemented. Provide adequate long-term care planning for inmates with chronic illnesses.
b. Ensure that inmates are provided adequate access to specialty care in accordance with generally accepted professional 'standards of care.
c. Ensure that pregnant inmates are provided adequate care in accordance with generally accepted professional standards of care.
11. Staffing, Training, and Supervision
a. Provide adequate staffing, training, and supervision of medical and correctional staff necessary to ensure adequate medical care is provided.
b. Ensure that medical staffing is adequate for inmates' serious medical needs and that physicians adequately monitor their patients.
c. Provide adequate physician oversight and supervision of medical staff.
d. Ensure that there is an adequate number of correctional officers to escort inmates to medical units.

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12. Dental Care
a. Ensure that inmates receive adequate dental care in accordarice with generally accepted professional standards of care. Such care should be provided in a timely manner.
13. Quality Assurance Review
a. Ensure that CCJ's quality assurance system is adequate to identify and correct serious deficiencies with the medical system.
b. Ensure that CCJ's quality assurance system is capable of assisting in managing and treating inmate medical needs. At a minimum, such a system should be reliable and capable of tracking medical related incidents.
B. Mental Health Care:
1. Timely and Appropriately Evaluate Inmates
a. Ensure CCJ properly identifies inmates with mental illness through adequate screening.
b. Ensure that inmates with potentially serious chronic mental health illness are referred for prompt mental health evaluations and examinations by a psychiatrist.
c. Provide adequate mental health assessment and treatment in accordance with generally accepted professional standards of mental health care.
d. Ensure that adequate crisis services are available to address the psychiatric emergencies of inmates.
e. Provide staffing adequate for inmates' serious mental health needs. Provide adequate on-site· psychiatry coverage. Ensure that psychiatrists see inmates in a timely manner. Ensure that psychotropic medication prescriptions are reviewed by a psychiatrist on a regular, timely basis.
f. Provide adequate screening to properly identify inmates with mental illness. Ensure that CCJ's intake evaluation process includes a mental health

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screening that is incorporated into an inmate's medical record.
g. Develop and implement an appropriate intake screening instrument that identifies mental health needs, and ensure timely access to a mental health professional when presenting sYmptoms require such care.
2. Assessment and Treatment
a. Ensure that treatment plans adequately address inmates' serious mental health needs and that the. plans contain interventions specifically tailored to the-inmates' diagnoses and problems. Provide therapy services where necessary for inmates with serious mental health needs. Provide adequate opportunities for inmates and staff to have confidential communications related to mental health treatment, while maintaining appropriate security precautions.
b. Ensure that mental health evaluations done as part of the disciplinary process include recommendations based on the inmate's mental health status.
c. Provide adequate on-site psychiatry coverage for inmates' serious mental health needs. Ensure that psychiatrists see inmates in a timely manner and that psychotropic medication orders are reviewed by a psychiatrist on a regular, timely basis.
d. Ensure that medications are provided to inmates in a timely manner and that they are properly monitored.
e~ Provide staffing adequate for inmates with serious mental health needs. Ensure that services, such as distribution of medications, are performed by nurses or other properly trained staff.
f. Provide policies and procedures that appropriately assess inmates with mental illness.
g. Provide adequate medical documentation and general procedures as part of the mental health

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assessments that accounts for inmates' psychiatric histories.
h. Develop and implement an appropriate intake screening instrument that identifies mental health needs, and ensure timely access to the mental health professional when presenting sYmptoms require such care.
3. Psychotherapeutic Medication Administration
a. Ensure timely responses to orders for medication and laboratory tests, and prompt documentation thereof in inmates' charts.
b. Ensure that adequate psychotherapeutic medication administration is provided in accordance with generally accepted professional mental health care standards.
c. Ensure that changes to inmates' psychotropic medications are clinically justified. Screen inmates on psychotropic medications for movement disorders and provide treatment where appropriate.
d. Ensure that inmates receive adequate screening and evaluation for the administration of psychotropic medications in a timely manner.
4. Other Mental Health Issues
a. Ensure that administrative segregation and observation status are not used to punish inmates for sYmptoms of mental illness and behaviors that are, because of mental illness, beyond their control.
b. Ensure that CCJ mental health records are centralized, complete, and accurate.
c. Ensure that CCJ quality assurance system is adequate to identify and correct serious deficiencies with the mental health system.
d. Ensure that a psychiatrist or physician conducts an in-person evaluation of an inmate prior to a seclusion or restraint order, or as soon thereafter as possible. Seclusion or restraint

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orders should include sufficient criteria for release.
e. Ensure that all staff who directly interact with inmates (including Correctional Officers) receive competency-based training 'on basic mental health information (e.g., diagnosis, specific problematic behaviors, psychiatric medication, additional areas of concern); recognition of signs and symptoms evidencing a response to trauma; and the appropriate use of force for inmates who suffer from mental illness.
D. Suicide Prevention Measure~
1. Provide adequate treatment for inmates with selfinjurious behavior.
2. Develop policies and procedures to ensure appropriate management of suicidal inmates and the establishment of a suicide prevention program.
3. Ensure that all staff are educated and adequately trained on suicide recognition and intervention, including pre-service and annual in-service suicide prevention training.
4. Provide a curriculum for pre-service and annual inservice competency-based suicide prevention training that includes an array of topics so that staff are adequately trained to identify and manage suicide.
5. Ensure that, prior to assuming their duties and on a regular basis thereafter, all staff who work directly with inmates have demonstrated competence in identifying and managing suicide.
6. Ensure that CCJ suicide prevention policies include an operational description of the requirements for both pre-service and annual in-service training.
7. Ensure that any staff who are exempt from suicide prevention training have limited inmate contact.
8. Screen all inmates upon intake, including questioning to assess current and past suicide risk.

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9. Document inmate suicide attempts at CCJ in the 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 admitted to CCJ again in the future.
10. Ensure that intake staff are sufficiently experienced and qualified to identify inmates that pose a risk for suicide, and conduct appropriate follow-up evaluations by mental health professionals of new inmates within 14 days of intake.
11. Ensure that inmates on suicide precautions receive adequate mental status examinations by a mental health clinician.
12. Ensure that suicidal inmates are housed in an area that. is safe for them with appropriate supervision and observation by staff.
13. Ensure that 15- and 30-minute checks of inmates under observation for risk of suicide are timely performed and appropriately documented.
14. Provide different levels of supervision of an inmate based on the pr~senting risk factors for suicide.
15. Ensure that detainees placed on suicide watch are assessed adequately, monitored appropriately to ensure their health and safety, and released from suicide watch as their clinical condition indicates according to professional standards of care.
16. Ensure that cut-down tools are readily available to staff in all housing units. Train staff in use of cut-down tools.
17. Ensure a component of administrative review is implemented following a suicide or a suicide attempt to identify what could have been done to prevent the suicide.
E. Fire and Life Safety
1. Ensure that all facilities have adequate fire and life safety equipment which is properly maintained and inspected.

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2. Implement competency based testing for staff regarding fire/emergency procedures.
3. Develop and implement adequate policies and procedures regarding fire prevention including emergency planning and drills.
4. Ensure that emergency keys are appropriately marked r available r and consistently stored in a quickly accessible location.
5. Ensure that fire alarms are installed and maintained in all housing areas.
6. Inventory and store all flammable r toxic r and caustic materials in a well ventilatedr but locked r compartment.
7. Ensure that emergency drills are conducted on a regular basis.
F. Sanitation and Environmental Conditions
1. Sanitation and Maintenance of Facilities
a. Develop and implement policies and procedures to ensure adequate cleaning and maintenance of the facilities with meaningful inspection processes and documentation. Such policies should include oversight and supervisionr as well as establish daily cleaning requirements for toilets r showers r and housing units.
b. Ensure prompt and proper maintenance of shower r toilet r and sink units.
c. Ensure proper ventilation and airflow in all cells and housing units.
d. Ensure adequate lighting in all housing units and prompt replacement and repair of malfunctioning lighting fixtures.
e. Ensure adequate pest control r including sufficient staffing for routine and follow-up pest control services.

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f. Ensure that all inmates have access to needed hygiene supplies.
g. Develop and implement policies and procedures for cleaning, handling, storing, and disposing of biohazardous materials.
h. Use cleaning chemicals that sufficiently destroy the pathogens and organisms in biohazard spills.
i. Secure all sharp medical tools.
j. Destroy any mattress that cannot be sanitized sufficiently to kill any possible bacteria. Inspect and replace as often as needed all frayed and cracked mattresses.
k. Develop a plan to reduce and prevent triplebunking of inmates in cells designed for two inmates.
1. When triple-bunking of inmates is unavoidable, provide a stackable bunk, moveable platform, or cot for each triple-bunked cell, so that inmates are not required to sleep with the mattress directly on the cell floor.
3. Environmental Control
a. Ensure adequate control and observation of CCJ cells, particularly with regard to razors, fire loading materials, commissary items, and cleaning supplies.
b. Repair electrical shock hazards; develop and implement a system for maintenance and repair of electrical outlets, devices, and exposed electrical wires.

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4. Sani~ary Laundry Procedures
a. Ensure that laundry delivery procedures .protect inmates from exposure to contagious disease, bodily fluids, and pathogens by preventing clean laundry from coming into contact with dirty laundry or contaminated surfaces.
b. To limit the spread of MRSA and other infectious disease, require inmates to provide all clothing and linens for CCJ laundering and prevent inmates from washing and drying laundry outside the formal procedures.
c. To limit,the spread of MRSA and other infectious disease, ensure that clothing and linens returned from off-site laundry facility are clean, sanitized, and completely dry.
d. Provide all inmates with properly cleaned and adequate bedding and clothing.
5. Food Service
a. Provide training for kitchen workers in the areas of food safety and food handling to reduce the risk of food contamination and food-borne illnesses.
b. Ensure that dishes and utensils, food preparation and storage areas, and vehicles and containers used to transport food are properly cleaned and sanitized.
c. Ensure that foods are served and maintained at proper temperatures.
*******
Please note that this findings letter is a public document. It will be posted 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

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regarding CCJ. Assuming there is a continuing spirit of cooperation from the County, we also would be 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.
We are obligated 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 facility'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, or Joan Laser, of the United States Attorney's Office, at (312) 353-1857.
Sincerely,
>4~~~ Grace Chung Becker Acting Assistant Attorney General
Patrick J. Fitzgerald United States Attorney Northern District of Illinois
cc: Salvador Godinez Executive Director Cook County Department of Corrections

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Patrick T. Driscoll, Jr. Chief, Civil Actions Bureau Office of the Cook County State's Attorney
Donald J. Pechous Assistant State's Attorney Office of the Cook County State's Attorney
Peter M. Kramer, Esq. General Counsel Cook County Sheriff's Office
Daniel F. Gallagher, Esq. Querrey & Harrow Counsel for the Sheriff's Office
Paul A. O'Grady, Esq. Querrey & Harrow Counsel for the Sheriff's Office