Case 3:13-cv-00646-JRS Document 1 Filed 09/20/13 Page 1 of 7 PageID# 1

~ IN THE UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF VIRGINIA Richmond Division

SEP 202013

CLERK, U.S. DISTRICT COURT RICHMOND VA

UNITED STATES OF AMERICA,

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PLAINTIFF,

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v.

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PIEDMONT REGIONAL JAIL AUTHORITY, )

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DEFENDANT.

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Civil No. 0 : t.e>C.-YCo~

COMPLAINT PLAINTIFF, THE UNITED STATES OF AMERICA ("Plaintiff'), by its undersigned attorneys, hereby alleges upon information and belief: 1. The Attorney General files this Complaint on behalf of the United States of America pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997, to enjoin the named Defendant from depriving persons incarcerated at the Piedmont Regional Jail ("Piedmont") in Farmville, Virginia, of rights, privileges, or immunities secured and protected by the Constitution of the United States.
JURISDICTION AND VENUE 2. This Court has jurisdiction over this action under 28 U.S.C. § 1345. 3. The United States is authorized to initiate this action pursuant to 42 U.S.C. § 1997a. 4. The Attorney General has certified that all pre-filing requirements specified in 42 U.S.C.
§ 1997b have been met. The Certificate of the Attorney General is appended to this Complaint as Attachment A and is incorporated herein.

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5. Venue in the United States District Court for the Eastern District of Virginia is proper pursuant to 28 U.S.C. § 1391. PARTIES
6. Plaintiff is the UNITED STATES OF AMERICA. 7. Defendant PIEDMONT REGIONAL JAIL AUTHORITY is a governmental subdivision
created under the laws of the State of Virginia and governed by the Piedmont Regional Jail Board of Directors. 8. Defendant is legally responsible, in whole or in part, for the operation and conditions of Piedmont, and for the health and safety of persons incarcerated there. This action concerns the administration of persons confined at Piedmont, which houses pre-trial federal and state detainees and sentenced prisoners. 9. At all relevant times, defendant has acted or failed to act, as alleged herein, under color of state law.
FACTS 10. Piedmont is an institution within the meaning of 42 U.S.C. § 1997(1). 11. Persons confmed to Piedmont include both pre-trial federal and state detainees and
sentenced prisoners. 12. The United States, pursuant to an investigation of Piedmont, has determined that Piedmont,
through its acts and omissions, engages in a pattern or practice of deliberately disregarding known or serious risks of harm to prisoners at Piedmont. 13. The United States' investigation included an onsite inspection with a correctional medical consultant, during which Department of Justice representatives toured the jail, observed

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-3processes, interviewed staff and prisoners, and reviewed a wide array of documents, including policies, procedures, and medical records. 14. The United States' findings are outlined in its September 6,2012 Letter of Findings, attached and incorporated herein by reference. The United States made several findings regarding constitutional violations at Piedmont, including those described in paragraphs 15-24 below. 15. Defendant has failed to take reasonable measures to protect prisoners against serious harm by permitting unqualified personnel to evaluate and manage serious medical conditions. Defendant uses certified nursing assistants (CNAs) to practice and provide medical care beyond their training and licensure, including managing sick call, and uses security officers to evaluate prisoners and clear them without any medical input or consultation. 16. Defendant's medical policies are lacking detail, and Defendant has no policies governing certain important medical subjects, such as infection control. 17. Defendant does not adequately screen incoming prisoners for medical issues, and even when screenings are performed, they are often not sufficiently documented. 18. Defendant has no chronic care program, and thus prisoners with medical and mental health issues are not properly identified and tracked. 19. Defendant has no system for providing thorough health assessments, and therefore medical problems often go undiagnosed or mistreated. 20. Defendant has no quality assurance program, so Defendant is unable to identify problems in the delivery of medical care and forge solutions to those problems. 21. Defendant has not adequately trained its staff on suicide prevention, mental health care, and first-responder medical care.

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22. Defendant charges excessive co-payments for prisoners to access medical care, in some cases charging as high as fifty dollars. Such co-payments effectively deter prisoners from seeking needed medical treatment.
23. Defendant provides inadequate mental health care to prisoners. Mental health staffing is limited, and Defendant does not provide mental health evaluations for prisoners with a history of mental illness or those on psychotropic medications.
24. Defendant does not adequately supervise prisoners on suicide watch, or provide timely and appropriate means for prisoners to be released from suicide watch.
25. The factual allegations set forth in paragraphs 15 through 24 have been obvious and known to Defendant for a substantial period of time, yet Defendant has deliberately failed to adequately address the conditions described.
VIOLATIONS ALLEGED
26. The allegations of Paragraphs 1 through 25 are hereby re-alleged and incorporated by reference.
27. Through the acts and omissions alleged in paragraphs 15 through 24, Defendant has subjected prisoners at Piedmont to a pattern and practice of conditions of confinement which deprive them of rights, privileges, and immunities secured and protected under the Constitution of the United States, causing such prisoners to suffer grievous harm. U.S. Const. Amends. VIII and XIV.
28. Through the acts and omissions alleged in paragraphs 15 through 24, Defendant has exhibited deliberate indifference to the health and safety of Piedmont prisoners, in violation

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ofthe rightst privilegest or immunities of those prisoners as secured or protected by the Constitution of the United States. U.S. Const. Amends. VIII and XIV. 29. Unless restrained by this Courtt Defendant will continue to engage in the acts and omissionst set forth in paragraphs 15 through 24t that deprive persons confined at Piedmont of privileges or immunities secured or protected by the Constitution of the United States.
PRAYER FOR RELIEF 30. The Attorney General is authorized under 42 U.S.C. § 1997 to seek equitable and
declaratory relief. 31. WHEREFOREt the United States prays that this Court enter an order:
a. declaring that the actst omissionst and practices of Defendant set forth in paragraphs 15 through 24 above constitute a pattern or practice of conduct that deprives prisoners confined at Piedmont of rightSt privilegest or immunities secured or protected by the Constitution of the United States and that those actst omissionst and practices violate the Constitution ofthe United States;
b. permanently enjoining Defendantt its officerst agentst employeest subordinates, successors in officet and all those acting in concert or participation with it from continuing the acts, omissions, and practices set forth in paragraphs 15 through 24 above and requiring Defendant to take such actions as will ensure lawful conditions of confinement are afforded to prisoners at Piedmont; and
c. granting such other and further equitable relief as it may deem just and proper.

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FOR THE UNITED STATES:

-6Respectfully submitted,
ERIC H. HOLDER, JR.
Attorney General United States

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KATHLEEN M. KAHOE

JOCELYN SAMUELS

ACTING UNITED STATES ATIORNEY Acting Assistant Attorney General

Civil Rights Division

BY:P»JJI j)Jf--
Robert P. McIntosh Virginia Bar Number 66113 Assistant United States Attorney United States Attorney's Office 600 East Main Street, Suite 1800 Richmond, Virginia 23219 Telephone: (804) 819-5400 Facsimile: (804) 819-7417 Email: Robert.McIntosh@usdoj.gov

Deputy Chief Special Litigation Section
~ L ;-~ . .
AARON S. FLEISHER Trial Attorney Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW PHB 5912 Washington, DC 20530 Telephone: (202) 307-6457 Facsimile: (202) 514-6903 Email: aaron.fleisher(@'usdoj.gov

 
 Case 3:13-cv-00646-JRS Document 1-2 Filed 09/20/13 Page 2 of 20 PageID# 11 U.S. Department of Justice
Civil Rights Division

A:uinanl Allnmt)· General

\liullingtmr, D.C. 20.UIJ
SEP- 6 2012

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VIA U.S. MAIL
Mr. James Garnett Chairman, Board of Directors Piedmont Regional Jail 801 Industrial Road Farmville, VA 23901
Re: Investigation of Piedmont Regional Jail. pursuant to the Civil Rights of Institutionalized Persons Act. 42 U.S.C. § 1997. and the Religious Land Use and Institutionalized Persons Act of2000 C"RLUIPA'')
Dear Mr. Garnett:
The Civil Rights Division ofthe United States Department of Justice has concluded its investigation ofconditions at the Piedmont Regional Jail ("Piedmont," ''the Facility," or ''the Jail''), pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA''), and the Religious Land Use and Institutionalized Persons Act of2000 {"RLUIPA").
Our investigation found reasonable cause to believe that the Jail is denying necessary medical and mental health care, and consequently places prisoners at an unreasonable risk of serious harm, in violation ofthe Constitution. These lapses, if not corrected, have a likelihood of resulting in unnecessary injury and/or loss of life. By implementing the corrective measures set forth below, the Jail will fulfill its duty to protect the health and safety of those in its custody.
We also found that the Jail does not currently violate RLUIPA. During our tour, we identified practices that may have created a substantial burden on the religious exercise of prisoners. The Jail immediately made changes in response to our recommendations that resolved the issue.
During our exit briefing, the Piedmont leadership expressed a desire and intent to rectify any problems identified by the investigation. We look forward to discussing our findings with you after you have had the opportunity to review this letter. The Jail is an integral part ofthe public safety system. The remedies we propose will ensure respect for the rights of prisoners

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confmed there and will also provide for the safety ofstaff and promote public safety in the community.
I. Investigation
On March 4, 2011, we notified you that we were opening an investigation ofPiedmont pursuant to CRIPA and RLUIPA. Our initial inquiry was prom~ted, in part, by a series of allegedly preventable deaths in the Jail between 2006 and 2009. We learned from our inquiry that the circumstances of some of these deaths indicated a possible pattern of deliberate indifference to prisoners• serious medical needs and we thus opened a formal investigation. In addition, we had received information that Piedmont was placing undue burdens on Muslim prisoners' ability to observe the tenets of their religion.
We requested and reviewed documents provided by Piedmont and, on June 16-17, 2011, we conducted an onsite inspection of the Jail. During our onsite inspection, we were accompanied by a correctional medical care consultant. We toured the Facility, observed Facility processes, interviewed staff and prisoners, and reviewed an array ofdocuments, including policies, procedures, and medical records. Consistent \vith our pledge of transparency, and to provide technical assistance where appropriate, we conveyed our preliminary determinations to Piedmont administrators during a telephonic exit presentation following our onsite visit. We conducted a brief follow-up site-visit on March 6, 2012.
Piedmont leadership was cooperative and professional throughout our investigation. We are particularly grateful to Superintendent Ernest Toney and the entire Piedmont staff. Piedmont has provided us with access to prisoner records and personnel, and responded to our requests before, during, and after our onsite visit in a transparent and forthcoming manner. We also appreciate Piedmont's receptiveness to our consultant's onsite and post-tour recommendations, and note that the Piedmont administration has, to date, consistently followed through on its expressed commitment to working with the United States to provide prisoners with reasonably safe and humane conditions of confinement, as required by the Constitution.
II. Background
Piedmont is a minimum to high-security facility located in Farmville, Virginia, situated between the cities ofRichmond and Lynchburg. The Jail serves six counties (Amelia, Buckingham, Cumberland, Lunenburg, Nottoway, and Prince Edward), and is administered by a board consisting of two members from each county. The current Superintendent of the Jail is Ernest Toney.
Piedmont opened in 1988 with capacity for approximately 100 prisoners, but has expanded over the years. The Jail's capacity is now approximately 800, and at the time of our onsite tour, there were approximately 660 prisoners housed at Piedmont. Piedmont houses pretrial detainees and convicted prisoners.
It is our understanding that after the last death during this time period, the U.S. Immigration and Customs Enforcement ("ICE") concluded that medical practice at Piedmont was below ac:c:epted community standards, and determined that the Facility could no longer be used to house ICE detainees.

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III. Findings
We find that deficiencies in the medical and mental health care provided to prisoners at Piedmont place prisoners at a substantial risk of serious harm. We further find that, during our investigation, the Jail acknowledged and began respecting the religious rights of all prisoners. Our findings are detailed below.
A. Medical Care at Piedmont Is Deficient and Creates Substantial Risks
Piedmont's system for the delivery of medical services places prisoners at an unreasonable risk ofharm. The Eighth Amendment affords convicted prisoners protection from cruel and unusual punishment U.S. CONST. amend. VIII. The constitutional rights ofpre-trial detainees are guaranteed by the Fourteenth Amendment, which, the Supreme Court has consistently held, provides protection at least equal to the Eighth Amendment. Bell v. Wolfish, 441 U.S. 520, 545 (1979). The Eighth Amendment requires prison officials to ''provide prisoners with adequate food, shelter, clothing, and medical care." Smith v. Davis, No. 7: 10-cv00263, 2011 WL 3880944 (W.O. Va. Sept. 1, 20ll)(citing Farmerv. Brennan, 511 U.S. 825, 832 (1994)).
The Constitution protects prisoners not only against ongoing harms, but also against the risk of future harm. Helling v. McKinney, 509 U.S. 25, 33 (1993) ("That the Eighth Amendment protects against future harm to inmates is not a novel proposition .... It would be odd to deny an injunction to inmates who plainly proved an unsafe, life-threatening condition in their prison on the ground that nothing yet had happened to them."). Conditions posing a substantial risk of serious harm to prisoners therefore violate the Constitution, even if no prisoner has suffered actual harm at the time the violation is found. See Farmer, 511 U.S. at 845-47; Helling, 509 U.S. at 35 (finding that risk of future harm to prisoner's health stated a cause of action under the Eighth Amendment); Harden v. Green, No. 01-6393, 27 Fed. App'x. 173, 177 (4th Cir. 2001) (noting that the Eighth Amendment "embraces the treatment of medical conditions which may cause future health problems''). The Supreme Court has clearly stated that "a remedy for unsafe conditions need not await a tragic event" Helling, 509 U.S. at 33.
Many of the lapses we identify below are directly related to Piedmont's inadequate medical staffmg. There is too little onsite coverage by properly licensed staffmembers, forcing certified nursing assistants (CNAs) to practice and provide medical care beyond their training and licensure. The lack of sufficiently trained and available medical staff for the management and evaluation ofserious medical conditions places prisoners at risk ohmnecessary harm and is deliberately indifferent to prisoners' serious medical needs. Prison officials, including doctors, ''violate the civil rights ofinmates when they display 'deliberate indifference to serious medical needs.,., Gordon v. Kidd, 911 F.2d 1087, 1094 (4th Cir. 1992) (citing Estelle v. Gamble, 429 U.S. 97, 104 (1976)). Prison officials knowingly disregard, or act with deliberate indifference to, prisoners' rights by ·~ntentionally denying or delaying access to medical care or intentionally interfering with the treatment once prescribed." Smith v. Smith, 589 F.3d 736, 738-39 (4th Cir. 2009) (citing Estelle, 429 U.S. at 104-05). Officials also violate the Constitution when they are deliberately indifferent to "an unreasonable risk of serious damage to ... [a prisoner's] future health." Helling, 509 U.S. at 35.

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1. Piedmont exposes prisoners to risk ofharm by relying on unqualified staffto perform essential medicalfunctions.
Perhaps the most significant single concern we have with the provision of medical and mental health care at the Facility is that staffmembers routinely perform medical services beyond what they are trained and credentialed to do. Piedmont's failure to ensure properly trained and credentialed staffing is to be expected, given its physician's indifference to such standards: while testifying under oath in March 2012, he stated that he was not aware of the staffmg standards mandated by Virginia regarding medical staff at correctional facilities. Our finding is also consistent with the findings of other experts and inspecting bodies, who have made similar fmdings in recent reviews of Piedmont's medical services.
The Facility has one physician and two Licensed Professional Nurses (LPNs). The lead LPN is the primary liaison for medical services at the Jail. The rest of the medical staffconsists of eight CNAs, and one mental health counselor. CNAs are not nurses, and must not be substituted for nursing staff. Per the Virginia Nursing Board, CNAs cannot be used to perform the following: activities involving nursing assessment, problem identification, or outcome evaluation requiring independent nursing judgment; coordination or management of care involving collaboration, consultation and referral; and emergency and nonemergency triage. Despite these prohibitions, CNAs perform many of these tasks at Piedmont, including receiving verbal medication orders. This is a dangerous practice that violates state licensure laws. CNAs' activities should be limited to taking vital signs, prepping patient charts, and other support functions.
A further concern involves "medical" security officers. We reviewed several incidents in which security staff were used to evaluate prisoner injuries, and cleared the prisoners without any medical input or consultation. Any clinical support by corrections officers must be limited, must be overseen by the medical department, and must be guided by clear protocols. Corrections officials may, and in fact, should, respond to medical emergencies in acute, life-threatening situations and be properly trained to do so. They should never, however, evaluate prisoners for medical reasons, perform sick call, or provide any type ofnon-emergency care. There are no protocols in place at Piedmont to guide corrections officers in the very limited medical tasks they may perform, and the current level of medical department oversight of officers is insufficient.
CNAs and nurses are forced to practice beyond their licenses because properly credentialed staff are simply not onsite for adequate hours to provide sufficient care for the prisoner population. The National Commission on Correctional Health Care (NCCHC) recommends that for every 100 prisoners, there should be at least 3.5 hours of physician time each week. Based on that recommendation and the census at the time of our visit to the Facility, there should be roughly 23 hours of physician time each week at Piedmont. The physician, however, is only onsite for 15 hours each week. As a result, he is not able to see all the prisoners that require physician care. While the physician asserted that he is available on an "on call" basis 24 hours per day, 365 days per year, the bulk of our review did not support this assertion.
When unlicensed staffmembers are permitted to play a key role in the delivery ofhealth care, the probability for harm is greatly increased. Medical staff members are not

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interchangeable. Registered Nurses (RNs), for instance, can perform functions that LPNs cannot, and LPNs can perform functions that CNAs cannot While highly trained and supervised nurses are the foundation of most effective correctional medical programs, a physician provides the medical program with clinical leadership and direction. A nurse cannot independently make a medical diagnosis. It is critical that nurses, or any other staff members, are not placed in positions in which they find themselves delivering health care that is beyond their scope of training. This concern arises in numerous areas at Piedmont, including, for example, practices related to prisoners experiencing alcohol withdrawal, who should be closely monitored by a physician to ensure their safety. Although Piedmont does have an alcohol withdrawal protocol, nurses implementing the protocol are not supervised by the physician.
These concerns should be addressed as soon as possible. Current practice, in which health support personnel are functioning well beyond their qualifications, compromises access to care for prisoners and puts prisoners at risk of injury or even death. Current practices also put staff members at risk oflosing their licenses, and both staff and the Jail at risk oflegalliability. Where medical staff members "are continually called upon to perform services for which they have not been trained and for which they are not qualified," a correctional facility effectively
denies prisoners access to medical care. Newman v. Alabama, 349 F. Supp. 278,283 (M.D. Ala 1972), aff'd in part, 503 F.2d 1320 (5th Cir. 1974), vacated in part on other grounds, 522 F.2d 71 (5th Cir. 1975) (en bane); see also Ramos v. Lamm, 639 F.2d 559, 575-76, 578 (lOth Cir.
1980) (affirming district court's finding that use of non-physician medical personnel to make decisions and perform services for which they were neither trained nor qualified demonstrated deliberate indifference to serious medical needs and constituted effective denial of access to
adequate medical care); Garner v. Winn Corr. Ctr., No. 1:08-CV-01977, 2011 WL 2011502, at *5 (W.D. La May 18, 2011) (providing LPN to evaluate and "diagnose" prisoners ''is a failure to
provide appropriate medical care to the inmates for which responsible prison officials may be
liable"); Gibson v. County ofWashoe, Nev., 290 F.3d 1175, 1187 (9th Cir. 2002) (''In order to
comply with their duty not to engage in acts evidencing deliberate indifference to inmates' medical and psychiatric needs, jails must provide medical staff who are 'competent to deal with
prisoners' problems."'), citing Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir.1982).
Piedmont should adjust staffing to increase the number of higher-trained staff, such as LPNs and RNs, as well as the number of hours that nurses and the doctor are onsite. Specifically, the Facility should hire at least two RNs, and add 6 LPNs, thus reducing the need for CNAs. In addition, the physician should be onsite no fewer than 23 hours per week. Further, corrections officers should never evaluate prisoners for medical needs, except as necessary to provide emergency care. Finally, Piedmont should revise its policies and procedures to establish clearly the expectations for all medical staff.
2. Piedmont's medicalpolicies lack specificity and thoroughness.
While Piedmont does have a medical manual, many of the policies are lacking in detail or specificity. There are no policies on chronic care, infection control, or quality assurance. The policies related to mental health care, and specifically those regarding potentially suicidal prisoners, do not provide the guidance necessary to prevent harm. Furthermore, Piedmont's policy to address the health concerns of pregnant women is limited in scope. In addition, the

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policy and protocol related to alcohol withdrawal are deficient. Problems related to medical policies and procedures at Piedmont are underscored by the recent, troubling testimony of Piedmont's physician, under oath, in which he confirmed that he has not reviewed medical policies and procedures for several years, despite the fact that he has signed forms stating that he did review them.
The Facility should review the 2008 NCCHC Jail Standards and use those standards as an outline to create and adopt policies specific to the Facility, focusing from the outset on the standards deemed "essential" by the NCCHC and supplementing those as necessary to meet the medical needs of prisoners at Piedmont. Piedmont should also consider implementing an assessment tool, such as the Clinical Institute Withdrawal Assessment tool, which would set up parameters for nurses who need to monitor prisoners placed under observation.
3. Intake screening procedures do notpromptly identifY medical problems.
Jails must provide a prompt medical screening upon intake, and refer prisoners with medical needs to doctors and nurses for further evaluation and treatment See Dawson v. Kendrick, 527 F. Supp. 1252, 1307 (S.D. W. Va 1981) (''It is generally recognized that prompt medical screening is a medical necessity in pre-trial detention facilities."). Failure to properly screen prisoners for communicable diseases may constitute deliberate indifference in violation of the Eighth Amendment. SeePorteev. Tollison, 753 F. Supp. 184, 186 (D. S.C. 1990), citing with approval Smith v. Sullivan, 553 F.2d 373 (5th Cir. 1977); Madrid v. Gomez, 889 F. Supp. 1146, 1257 (N.D. Cal. 1995) (''The facility should screen newly arrived inmates to identify potential medical problems and communicable diseases."), citing Lightfoot v. Walker, 486 F.
Supp. 504, 524 (S.D. DL 1980) (''Health care admission screening procedures, including a
physical examination performed by a physician, are an essential element of a constitutionally adequate system.').
The intake screening is the jail's first opportunity to identify the needs of new prisoners and consider treatment options. Without a proper screening mechanism, prisoners may be improperly denied necessary care or medication. Absent screening, prisoners may also enter the jail with communicable diseases that can, ifundiagnosed upon arrival, spread to the rest of the population.
Although Piedmont conducts some initial screening, the screening provided is inadequate, those conducting the screening are often not properly trained, and the results of the screening are documented inadequately, if at all. Some prisoners at the Facility are initially screened only by corrections officers, who are not trained in identifying medical or mental health needs and are not provided guidance regarding referrals to physicians. While corrections officers may perform an initial screening in rare, limited circumstances-such as during one or two quiet overnight shifts each week where medical personnel are not present-those officers must be adequately trained, and the screening must be followed by a full screening conducted by a member of the medical staffwithin hours.
Proper documentation, including any referrals for further evaluation, is vital for determining future treatment plans and ensuring that prisoners can be monitored. We reviewed

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numerous medical records that did not contain any documentation reflecting the results of the initial screening. While we did observe some screenings, and received assurances that screenings are regularly conducted, it was impossible for us to verify that the Jail does indeed conduct a screening of each new prisoner.
We also found problems with subsequent screening for access to medical care. Like corrections officers, nurses, too, require guidance regarding which situations necessitate referrals to the physician, but Piedmont has not promulgated policies that would provide such guidance. Indeed, this deficiency was confirmed by the physician in March 2012, when he conceded that Piedmont currently has no medical manual of protocols available for the medical staff to consult Finally, as noted earlier, Piedmont permits CNAs to perform medical screening, which they should not be doing.
In order to correct these deficiencies, Piedmont should develop and implement an intake screening system that instructs screeners regarding which prisoners should be referred to physicians and when; ensures documentation of all information obtained through the screening process; and ensures that individuals conducting screenings and controlling access to medical care are appropriately trained and qualified.
4. Piedmont's lack ofa chronic care program places prisoners at risk ofhann.
Piedmont's lack ofa chronic care program places prisoners at an unreasonable risk of harm. A chronic care program is crucial to ensure that prisoners with known medical and mental health illnesses are identified and seen for an initial comprehensive evaluation, and then tracked to ensure periodic follow-up. A correctional institution's failure to implement policies and procedures that ensure that prisoners with chronic illnesses are identified and appropriately
treated exposes prisoners to serious risks of future harm. See Shepherd v. Dallas County, 591
F.3d 445, 453-54 (5th Cir. 2009) (finding that jail's lack of chronic care exposed detainee to risk
of serious injury and death); Sdnto v. Preston, 170 Fed. App'x. 834 (4th Cir. 2006) (failure to
provide adequate treatment for chronic diabetes constitutes deliberate indifference). The NCCHC categorizes a chronic care program as an essential element of correctional medical care, and has developed guidelines for disease control for diabetes, hypertension, HIV, pulmonary diseases, and seizures.
Chronic care programs prevent avoidable injuries and deaths by keeping chronically ill
individuals medically stable through mechanisms such as routine, scheduled clinic visits. At present, Piedmont has no defined systems in place to track or manage prisoners with chronic conditions. By the Facility physician's own admission, medical care at Piedmont is episodic or complaint-driven, rather than proactive. For example, a prisoner who suffers from migraines and had been at the Facility for over six months at the time of our visit, had to be sent to the hospital after experiencing numbness in his body, but after returning to the Facility, had never been checked by the physician. This case reveals weaknesses in both physician coverage and chronic care follow-up. Piedmont's lack of preventative/chronic care can result in harm or risk ofharm to prisoners. The following examples are illustrative:

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I I Prisoner A2 entered the Jail with a history of seizures. He was placed on Dilantin, a drug that can cause both neurological and cardiac side effects, but, despite the fact that he had been at the Jail for over eight months at the time of our inspection, was never evaluated for proper medication dosage or toxicity level.
I I Prisoner B reported a history of chronic obstructive lung disease and hypertension upon entering the Jail on March 18, 2010. He was placed on Theophylline, a toxic medication that should be used with caution, yet at the time of our review, he had never had a drug level to assess the toxicity and therapeutic levels of the medication, and had never been evaluated for complications associated with hypertension or cardiac risks, as would be expected. In fact, be had not had a visit with the physician to address his chronic conditions at all. Prisoner B was evaluated by a CNA on May 21, 2010 for chest pain, and was eventually sent to the hospital for his pain, yet he never had a follow-up visit with the physician for his chest pain.
1 I Prisoner C, at Piedmont since March 30,2010, was placed on Coumadin, a potent blood thinning medication, for heart disease, and Simvastatin for high cholesterol. Both of these medications can be toxic and need to be monitored for therapeutic effect. At the time of our review, no drug tests had been conducted and the physician had not scheduled any chronic care visits with Prisoner C.
I I Prisoner D entered the Jail with a history of hypothyroidism, mental illness, and hypertension. He was given medications to address these conditions, but no blood work was ever done to determine ifhis thyroid condition was responding to the medication or if he received the proper dosage. Piedmont medical staff also failed to monitor the drug used to adjust Prisoner D's cholesterol level, which placed him at great risk for undetected liver toxicity.
As the above examples illustrate, Piedmont's lack of a chronic care program exposes prisoners to a substantial risk of significant harm. To remedy this, Piedmont should establish a chronic care program that defines what illnesses qualify for inclusion in the program (for example: diabetes, hypertension, dyslipidemia, HN, cardiovascular diseases, seizure, pulmonary illness, and mental illness); ensures that prisoners with chronic care issues are identified and examined by the physician; tracks prisoners in the program and schedules periodic assessments; provides for diagnostic tests at an initial comprehensive visit; makes lab work available at appoinbnents in order to determine the status of disease control; and outlines a clinical plan for each chronically ill prisoner.
5. The lack ofcomprehensive health assessments places prisoners at risk.
Comprehensive health assessments, conducted within fourteen days of arrival, are an integral part of a correctional medical system, because they may identify medical problems that were not discovered during the initial screening process. See, e.g. Roberts v. Mahoning County,
2Prisoners are referred to by letter to protect their privacy.

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495 F. Supp. 2d 719,769 (E. D. Ohio 2007) (consent judgment requiring that new medical providers contracted by jail conduct comprehensive health assessments within fourteen days of prisoners' arrival at the jail).
Thorough health assessments, conducted after the prisoner has adjusted to the jail setting, are an essential tool for jail clinicians. Such assessments, in addition to identifying problems that were not raised or addressed in the initial screening, allow medical staff to develop more complete treatment plans for prisoners with known medical problems, including, for example, diabetes, asthma, and depression. Without a detailed evaluation of each prisoner, chronic or less immediately apparent problems can go undiagnosed or mistreated. The evaluation further allows medical staff to develop a medical baseline for each prisoner. Moreover, health assessments can assist in identifying and treating the spread of communicable diseases that can impact prisoners, staff, and the wider community. Deficiencies related to health assessments have been a subject of concern for other experts and inspecting bodies reviewing Piedmont's medical services in the past.
Piedmont should develop and implement a system to provide a comprehensive health assessment within fourteen days of the anival of each prisoner. A physician, physician assistant, or nurse practitioner should conduct the health assessments. However, RNs could perform health assessments, provided that a physician provides documented supervision and training.
6. Piedmont's sick call system places prisoners at risk ofhann.
Sick call systems are essential to the provision of adequate correctional medical care. Todaro v. Ward, 431 F. Supp. 1129, 1146 (S.D.N.Y. 1977) (''Courts have held that a sick call procedure for prompt referrals of those in need to a physician is constitutionally required."), affd sub nom. Todaro v. Coughlin, 652 F.2d 54 (2d Cir. 1981), and a.ffda 565 F.2d 48 (2d Cir. 1977) (citations omitted). The sick call system must be run by medical personnel who are appropriately trained in meeting the medical needs of the prisoner population. Madrid. 889 F. Supp. at 1258 (''While medical technical assistants or their equivalent may permissibly be the first to examine inmates with physical ailments, they must be properly trained to perform this function and adequately supervised.").
Prisoners rely on a jail's sick call system as an entry point to medical care \vithin the facility, and jails rely on a sick call system to ensure that medical problems are addressed as early as possible to prevent unnecessary suffering, avoidable injury or death, and the increased medical costs associated with illnesses that have been allowed to linger and worsen.
Currently, Piedmont's sick call system places prisoners at an unreasonable risk of harm, because under-qualified LPNs and CNAs manage the sick call system without the supervision of a physician. CNAs are not sufficiently credentialed to perform sick call or evaluate prisoners. The LPNs at Piedmont, although credentialed, currently lack the training necessary to develop long-term treatment plans. Furthermore, Piedmont lacks standardized forms for nurses to use in their evaluations. These forms, ifproperly developed, would guide nurses and establish protocols for referrals to the physician. Indeed, this deficiency was confirmed by the physician when he testified in March 2012 that Piedmont currently has no medical manual ofprotocols

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available for the medical staff to consult. Problems with Piedmont's sick call system are longstanding, and have been noted by other experts and inspectors in the past.
While changes to the current sick call system are required, we do note with approval that prisoners seem to be able to access the medical staff when necessary. Most prisoners we spoke with reported being seen by someone on the medical staff within days of submitting a sick call slip, and none reported problems accessing medical care for true emergencies. Our concern is whether prisoners' initial contact wit4 medical staff via the sick call system routinely results in the prisoner being referred for the appropriate level of care based on the prisoner's medical needs. Nonetheless, prisoners' ready access to sick call and emergency medical care is a positive development, and seems to represent improvement, as a lack of access to care allegedly led to several deaths and numerous other issues at the Facility in the past.
In order to address the problems related to sick call, Piedmont should establish standardized tools for use during sick call evaluations. These tools will allow nurses to properly triage prisoners' medical needs and ensure they are referred for and provided appropriate treatment in a timely manner. CNAs should not be allowed to perform clinical evaluations, and their role in the sick call process should be limited to prep work, such as taking vital signs. Further, the physician should provide oversight of the sick call process by periodically reviewing the nurses performing sick call, in order to ensure that personnel are not practicing beyond their clinical training.
7. The lack ofany quality assurance program at Piedmont puts prisoners at risk of harm.
Quality assurance ("QA"), or quality improvement, is an important tool for any correctional medical staff. See, e.g., Cody v. Hillard, 599 F. Supp. 1025, 1058 (D. S.D. 1984) (''Several courts have held the lack of quality control over medical care, when considered among other health care deficiencies, unconstitutional under the Eighth Amendment."), afJ'd~ 799 F.2d 447 (8th Cir. 1986) on reh'g:. 830 F.2d 912 (8th Cir. 1987).
A functioning, effective QA program \vill identify problems in the delivery of medical care, and create mechanisms to rectify those problems. One of the major components of a QA system is to share findings with staff so that they can learn from past mistakes. QA often involves the physician reviewing and analyzing nursing assessments and other critical clinical activities, such as chronic care and sick call. It should also involve the review of all deaths at the Facility, in order to ascertain compliance with the standard of care and educate staff about trends and causes of prisoner deaths. An effective QA process will improve the clinical care provided and reduce poor outcomes.
Piedmont currently bas no QA program, which means that it cannot be proactive in identifying problem areas before a poor clinical outcome occurs. The Facility should develop a QA program to review the clinical performance ofsick call, health assessments, intake, chronic care, medication administration, and emergency care. This QA program should include a comprehensive and documented mortality review and response after any deaths.

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8. Training gaps increase the likelihood ofham1.
As noted above, we reviewed several incidents in which security staff were used to evaluate prisoner injuries, and cleared the prisoners without any medical input or consultation. Corrections officials may and should respond to medical emergencies in acute, life-threatening situations. But they must be properly trained to do so and should not be asked to make the clinical-level evaluations they are asked to make at Piedmont A failure to train security and medical staff can cmJSe serious medical hann and subject an agency to legal liability. See, e.g., Doe v. Broderick, 225 F.3d 440,456 (4th Cir. 2000). While Piedmont does conduct training for medical and security staff, the training on suicide prevention and mental health is severely lacking. Training is necessary even where officers can call medical staff at any time, as officers are nearly always the first responders to a medical crisis and, with proper training, may be able to prevent more serious injury or even save a life.
Piedmont should ensure all officers are trained in providing ftrst-responder medical care. The Facility should also develop and implement training for suicide prevention and mental health.
9. Piedmont's co-pay system can result in denial ofaccess to care.
Policies which require that a prisoner pay a co-payment for health care do not constitute per se deliberate indifference to a serious medical need in violation ofthe Eighth Amendment. However, such co-payment policies can rise to the level of a constitutional violation where prisoners are denied access to necessary health care due to their inability to pay. See Johnson v. Dep 't ofPub. Safety & Corr. Services, 885 F. Supp. 817, 820 (D. Md. 1995); Gonzales-Reyno v. Ellis, No. 1:09-cv-522-AJTffCB, 2009 WL 2421482, at *3 (E.D. Va. July 27, 2009); Collins v. Romer, 962 F.2d 1508, 1513 (lOth Cir. 1992). Therefore, while jails may charge small co-pays for medical care, co-payment policies must be flexible to enable indigent and chronically ill prisoners to access health care without imposing unnecessary hardship. See Johnson, 885 F. Supp. 817, 820. Where these exceptions are not in place, even relatively small co-pays can create barriers to access to necessary health care.
At Piedmont, prisoners are required to pay considerable fees for most clinical services. Piedmont prisoners pay $12.50 to see a nurse and $20.00 to see the doctor, while emergency visits cost $50.00. Prisoners are charged $10.00 per month for medication. The amounts Piedmont charges far exceed the generally accepted co-payment amounts across the country. Most state correctional systems charge co-pays in the two to five dollar range, and rarely are they more than $10. See, e.g., http://www.michigan.gov/documents/corrections/03_04_1 01_268638_7.pdf ($5 co-pay in Michigan prisons); http://www.drc.ohio.gov/web/medical.htm ($3 co-pay in Ohio prisons); http:/lwww. portal. state.p a us/portal/server. pt/document/919468/820_copayment_for_medical_services_pdf ($5 co-pay in Pennsylvania prisons). In fact, the Virginia Department of Corrections charges a five dollar co-pay for most medical services. Virginia Dept. of Corrections, Operating Procedure 720.4: Co-Payment for Health Care Services, (amended Nov. 15, 2011), www.vadoc.state.va.us/about/procedures/documentsn00/720-4.pdf. Moreover, the co-pays charged by Piedmont are well in excess ofmost fees which have

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previously been found constitutional. See Johnson, 885 F. Supp. at 818 (co-pay oftwo dollars constitutional); Collins, 962 F.2d at 1517 (three dollar co-pay constitutional); Gonzales-Reyna, 2009 WL 2421482, at *3 (five dollar co-pay constitutional).
While the Piedmont inmate/detainee handbook and medical protocols make clear that prisoners cannot be denied access to medically necessary services based upon their inability to pay, there can be no doubt that, in actuality, inability to pay impacts whether prisoners request medical care. Numerous prisoners we spoke with said that the co-pay fees adversely affected their decisions whether to seek needed medical care, especially when paying for a medical appointment would mean foregoing hygienic or other items that the prisoner could otherwise purchase with the money he or she would have to use as a co-pay. Universally, the prisoners we spoke with who had been incarcerated at multiple facilities told us that Piedmont has the highest co-pays of any facility they had encountered.
The NCCHC has recognized numerous problems, like that illustrated above, created by medical co-pays, all ofwhich are only exacerbated when the co-pays are exceedingly high, as they are here. For example, co-pays place prisoners in the position of having to choose between paying for other much needed items, such as hygienic products, or receiving medical attention. Nat'l Comm'n on Corr. Health Care, Position Statement: Charging Inmates a Feefor Health Care Services (Oct. 2005), http://www.ncchc.org/resources/ statementslhealthfees.html. Further, when prisoners avoid medical care for what may initially be minor situations, those situations may deteriorate, leading to serious consequences for the inmate or the infection of others. ld Accordingly, the NCCHC has recommended a number of guidelines, including the following:
n Only services initiated by the inmate should be subject to a fee or other charges. No charges should be made for the following: admission health screening (medical, dental, and mental) or any required follow-up to the screening; the health assessments required by facility policy; emergency care and trauma care; hospitalization; infirmary care; prenatal care; in-house lab and diagnostic services; pharmacy medications to maintain health; diagnosis and treatment of contagious disease; chronic care or other staff-initiated care, including follow-up and referral visits; and mental health care including drug abuse and addiction.
n The assessment of a charge should be made after the fact The health care provider should be removed from the operation of collecting the fee.
n Charges should be small and not compounded when a patient is seen by more than one provider for the same circumstance.
n No inmate should be denied care because of a record of non-payment or current inability to pay for same.
n The system should allow for a minimum balance in the inmate's account, or provide another mechanism permitting the inmate to have access to necessary hygiene items (shampoo, shaving accessories, etc.) and over-the-counter medications. Jd
It remains an open question whether a $50 co-pay for emergency visits is per se unconstitutional. But even lower co-pays may be unconstitutional if they are shown to effectively deter legitimately needed medical treatment. At Piedmont, the exceedingly high co-

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pay fees, in combination with information indicating that they may be serving as a barrier to prisoners receiving necessary medical care, may well run afoul ofconstitutional requirements.
Accordingly, Piedmont should immediately revise the co-pay policy to exclude all health care required by the Facility, including health assessments and mental health care. In addition, Piedmont should establish exceptions to the co-pay requirement for necessary medical care, including chronic care and emergency visits, so that prisoners are not dissuaded from seeking and receiving care that is essential to their health. Furthermore, the Jail should require only a single, lower co-pay fee to see a nurse, with no further fee to see the doctor if the prisoner is referred for further evaluation. In addition, Piecbnont should establish a minimum balance in the prisoner's account, in order to ensure that a prisoner who is charged a co-payment will retain the ability to purchase hygiene items and over-the-counter medications.
B. Mental Health Care at Piedmont is Sub-Standard and Places Prisoners at Risk of Harm
Jails are constitutionally required to treat prisoners with mental health needs. Estelle, 429 U.S. at 104. Failure to properly treat and monitor individuals with suicidal thoughts or behaviors is a violation of the Eighth Amendment. Buffington v. Baltimore County, Md, 913 F.2d 113, 120 (4th Cir. 1990) ("where police know that a pretrial detainee is on the verge of suicide, that psychological condition can constitute the kind ofserious medical need to which state officials must, under the due process clause, not be deliberately indifferent"). Officials are also required to provide appropriate psychiatric services, including evaluation, treatment, and supervision, to protect prisoners from harming themselves or others. De'Lonta v. Angelone, 330 F.3d 630 (4th Cir. 2003) (protection against self-mutilation is serious medical need to which prison officials may not be deliberately indifferent); Dawson, 521 F. Supp. at 1308 ("... failure to provide timely access to ... psychiatric or psychological personnel" contributes to deliberate indifference).
Without proper evaluation and treatment, prisoners with serious mental illness may needlessly suffer and cause significant security challenges, becoming actively psychotic, aggressive, violent, or difficult to control.
While many mental illnesses are treatable with the right medications and therapy, a disjointed mental health system places prisoners at risk of injury and illness from improper medication or dosage levels, suffering the ongoing impact of untreated serious mental illness, and self-harm.
Piedmont's mental health care system is deficient in a number of ways:
Inadequate Psycltiatric Staff: The Jail has no psychiatrist available to prescribe psychotropic medications or evaluate their effects. This is a gross violation of standard medical practice. Instead, a clinical counselor, who is not a trained or licensed physician, serves as the sole mental health staff member, and is only present at the Jail for one day per week. She meets \vith patients only upon their request or upon a report of suicidal ideation or a suicidal act. Prisoners who are given psychotropic medication are not monitored for side effects or proper

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dosages. The American Psychiatric Association recommends that there be one full-time psychiatrist for every 75-150 patients with serious mental illness on psychotropic medication in
prison. At the time of our visit, there were 75 prisoners on mental health medications in the Facility, indicating the need for at least 20-40 homs of onsite psychiatric care. The Jail, in
contrast, provides none.
Inadequate Assessments and Follow-11p: Additionally, no routine mental health evaluations are performed, even for prisoners with a history of mental illness or those on psychotropic medications, and there are no documented assessments or treatment plans for prisoners with mental illness. Diagnostic blood tests, which are needed when certain medications are prescribed, are not routinely conducted or properly documented. For example, Prisoner E was prescribed Tegretol and Lithium for his mental illness. Both of these medications require periodic drug levels, due to their toxicity. Lithium, in particular, can be lethal ifnot managed correctly. Nevertheless, no drug levels were taken and Prisoner E had not, at the time of our review, had any follow-up to assess his mental status. We also reviewed the records of several other prisoners prescribed Lithium without blood work or other follow-up being performed.
Inadequate Suicide Prevendon: Prisoners at Piedmont who exhibit suicidal behavior or express suicidal thoughts are dealt with inappropriately. Prisoner F, who reported a history of suicidal ideation, was prescribed Haldol, but never received a comprehensive mental evaluation or any follow-up on the effects ofthe medication. Other suicide precautions are also lacking, such as staggered 15-minute checks of prisoners on suicide watch, and the availability of cutdown tools for officers. Significantly, because prisoners can only be released from suicide watch after being seen by the counselor, who works only one day a week, prisoners can be-and have been-on suicide watch for up to a full week unnecessarily. Maintaining prisoners on suicide watch unnecessarily is punitive and can discourage those who truly need help from seeking it. The physician should be actively involved in evaluating prisoners on suicide watch, but currently is not. For example, Prisoner G was placed on observation for almost a week with no physician evaluation, and there were no notes or documentation in her file regarding her treatment or progress.
To remedy these problems, Piedmont should ensure that prisoners with mental health needs are properly evaluated, treated, and monitored by a licensed psychiatrist who is onsite at least 20 hours per week. That psychiatrist should be supported by the clinical counselor, who
could work in conjunction with a nurse practitioner to provide a sufficient number of hours of
coverage each week. All prisoners with a known mental illness should be referred to the psychiatrist within fourteen days of arrival, assuming an initial screening is completed, and individuals with more acute needs-such as those who are suicidal or grossly psychotic-should be seen and treated as soon as the Facility becomes aware of their condition. Prisoners who are prescribed psychotropic medication should also be evaluated by the psychiatrist within two weeks of starting a new medication. Piedmont should develop and implement policies to ensure monitoring of individuals with chronic mental health illness, and completion ofblood work and other follow-up as necessary. Finally, all prisoners on suicide watch should be actively monitored to ensure that no prisoner is restricted longer than necessary.

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C. RLUIPA
We note, as a general matter, that we were pleased to see a number of recent changes that Piedmont bas made to ensure that it is in compliance with RLUIPA. These changes should be maintained, as they are both necessmy under the law and beneficial to the Facility and society at large. Prisoners who are permitted to practice their religion are less likely to engage in misbehavior or otherwise cause disruptions to the jail environment, and religious worship supports rehabilitation. See 146 CONG. REC. S6678-02, at S6689 (daily ed. July 13, 2000).
RLUIPA provides that no institution owned or operated by, or on behalf of, any State or local government, including correctional facilities, "shall impose a substantial burden on the religious exercise of a [resident]." 42 U.S.C. § 2000cc-1(a). This prohibition includes a substantial burden on religious exercise resulting from a rule of general applicability. Id ''Religious exercise" is defmed to include "any exercise ofreligion, whether or not compelled by, or central to, a system ofreligious belief." 42 U.S.C. § 2000cc-5(7)(A). In order to overcome this prohibition on burdening religious exercise, a government must demonstrate that imposition of the burden is: (1) "in furtherance of a compelling governmental interest''; and (2) "the least restrictive means of furthering that compelling governmental interest." 42 U.S.C. § 2000cc-l(a). The Fourth Circuit, in interpreting RLUIPA, bas held that a substantial burden occurs when an act or omission ''put[s] substantial pressure on an adherent to modify his behavior and to violate his beliefs." Lovelace v. Lee, 472 F.3d 174, 187 (4th Cir. 2006) (quoting Thomas v. Review Bd ofIndiana Employment Sec. Div., 450 U.S. 707,718 (1981)).
Below, we briefly address our observations about several discreet issues within the RLUIPA context Because allegations we bad previously received focused mainly on the denial of religious rights to Muslim prisoners, our comments center largely on that population.
1. Religious Meals
Piedmont serves a pork-free diet, which allows it to meet the needs of many of those prisoners who may adhere to a religious diet. Piedmont also provides special meal service to those observing Ramadan.
While the food service at Piedmont for religious observers thus seems to be adequate at present, the Jail should be aware that simply providing a pork-free diet may not be sufficient to accommodate all prisoners' religious exercise. Piedmont should ensure that prisoners can at least purchase from the commissmy religiously acceptable foods to augment the diet provided.
2. Religious Services
Piedmont currently permits Muslim prisoners to participate in a Ju'mah service each Friday. This practice began shortly after we issued our Notice Letter informing the Facility that we were opening our investigation. Piedmont should continue to allow Ju'mah services to ensure it is not in violation ofRLUIPA. We observed the Ju'mah service, in which the Jail's chaplain participated, and we appreciate his commitment to allowing prisoners of all faiths to practice their religions while incarcerated.

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3. Religious Possessions
After our investigation began, Piedmont started permitting Muslim prisoners to possess Korans. Prayer rugs, we were informed, are sold in the commissary, and we saw several prayer rugs being used during the Ju'mah service. Piedmont has fulfilled its legal obligation by permitting prisoners to practice their religion with the appropriate possessions. Piedmont should continue this practice to maintain compliance with federal law.
4. Religious Headwear
During our investigative tour, several Muslim prisoners informed us that, while they were allowed to wear religious headgear (the kufi) in their housing units, they were not permitted to wear them outside of those units. A Piedmont official confmned to us that this accurately represented policy.
After we raised this issue, Piedmont changed the policy so that religious headgear can now be worn throughout the Facility, but when a prisoner wearing such headgear enters or leaves a housing area or any Jail program, the headgear will be searched for contraband. Jail directives also now provide that prisoners shall have access to religious headwear. These policy changes should also remain in place, as they are necessary to ensure that the Facility is in compliance with its obligations under federal law.
IV. Summary of Remedial Measures
To remedy the deficiencies identified above, Piedmont should promptly implement the minimum remedial measures set forth below. Specifically, the Facility should:
I 1 Review the 2008 NCCHC Jail Standards and use those standards to create and adopt facility-specific policies, focusing from the outset on the standards deemed "essential'' by the NCCHC.
Revise medical policies to include policies on chronic care, infection control, and quality assurance.
1 1 Increase medical staffing by hiring additional staff with higher credentials (e.g. RNs, LPNs, and a psychiatrist) and increasing the hours that current staff-most especially the doctor-are onsite. Specifically, hire at least two RNs; add 6 LPNs, which will allow for a reduction in the number ofCNAs; increase the physician's onsite hours to at least 23 hours per week, and, in conjunction with hiring a psychiatrist, increase the mental health counselor's hours or hire a nurse practitioner to cover additional hours.
i : Limit the tasks that CNAs undertake to those that they are credentialed to perform, and ensure that proper physician supervision is provided. Specifically, among other things, CNAs should not be performing intake screenings or clinical evaluations, and should not take medication orders.

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i I Ensure that security officers are not rendering medical decisions regarding prisoners' care, and make sure that there are clear guidelines in place for any security officers providing clinical support, with physician oversight.
i 1 Ensure that all initial screenings are performed by trained staff and documented electronically, including documentation ofany referrals to the physician.
I 1 Implement a policy that provides guidance to nurses about when to refer prisoners to the physician following screening, sick call, or emergency visits.
1 : Conduct comprehensive health assessments of all prisoners within fourteen days of their arrival, with a physician either conducting the screening or overseeing RNs who conduct the screening.
, i Provide for physician oversight, including periodic review, of sick call, with nursing protocols and clinical assessment forms that guide the nurses performing sick call.
Develop a detox procedure that includes the Clinical Institute Withdrawal
Assessment tool for prisoners at risk of alcohol withdrawal and requires physician
input before nurses can treat prisoners withdrawing from abused substances.
i1 Implement a chronic care program that identifies prisoners for enrollment; defmes illnesses to be included; ensures that enrolled prisoners are tracked and scheduled for periodic assessments; requires diagnostic tests; and ensures that all prisoners with known medical or mental health issues are scheduled for routine visits with the physician or a psychiatrist as appropriate for their condition.
' ' Review and revise the co-pay policy to ensure that it does not prevent prisoners from accessing health care. The review should assess the co-pay amount to determine whether it is a deterrent to seeking care and make provisions for indigent prisoners and prisoners with chronic illness.
I I Provide routine evaluations to prisoners with a history of mental illness and those on psychotropic medication, with documented treatment plans, within 14 days of arrival .
. , Provide immediate treatment to prisoners who are suicidal or psychotic, as soon as those conditions are known to the Facility.
I 1 Ensure that the physician provides follow-up visits to prisoners on psychotropic medications, including diagnostic blood tests for prisoners on certain mental health drugs, based on the toxicity profile of the medication.

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; 1 Ensure that the physician sees prisoners on suicide watch when the mental health staff is not present, and ensure that prisoners are not kept on watch longer than necessary.
1 ' Ensure that 15-minute watches for prisoners on suicide watch are staggered, and ensure that all officers have cut-down tools.
, i Institute a quality assurance program that, among other things, reviews the clinical performance of sick cal~ the health assessment process, the intake process, the chronic care program, medication administration, and emergency care, and includes mortality reviews after any deaths.
Implement training on first-responder medical care, mental health and suicide prevention for security staff.
Continue to serve meals that allow prisoners to adhere to a religious diet, including special meal service for religious holidays, and establish a plan to meet the needs of prisoners who may require more than a pork-free diet in order to meet the dictates of their religion.
1 Continue to permit prisoners to participate in religious services, possess religious books and other materials (such as prayer rugs), and wear religious headgear throughout the Facility.
••••••••
We hope to continue working with Piedmont in an amicable and cooperative fashion to resolve the above-outlined concerns regarding conditions at the Facility. We know that, since our onsite visit, Piedmont has committed to taking various steps to address many of the issues we raised at our exit presentation. We appreciate the Jail's proactive efforts, which give reason to believe that the Jail will be able to resolve all the matters about which we have expressed concern.
We look forward to learning of the progress Piedmont has made thus far, and to discussing the above findings with the Jail. As always, we remain available to discuss any questions or concerns that you might have regarding our investigation.
Please note that this letter is a public document. It will be posted on the Civil Rights Division's website.

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Should you have any questions or concerns regarding this letter, please feel free to contact Jonathan M. Smith, Chief of the Civil Rights Division's Special Litigation Section, at (202) 514-5393.
Sincerely,

- - - - - - - ~- -~------~-- ~--~

-

----~---~ ~~~-~~

Thomas E. Perez Assistant Attorney General

cc: Neil H. MacBride, United States Attorney United States Attorney's Office Eastern District of Virginia
Mr. Ernest L. Toney Superintendent, Piedmont Regional Jail 801 Industrial Road Farmville, VA 23901
Robert A. Dybing, Esq. ThompsonMcMullan, P.C. 100 Shockoe Slip Richmond, VA 23219

 
 Case 3:13-cv-00646-JRS Document 3-2 Filed 09/20/13 Page 1 of 41 PageID# 40

IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA
Richmond Division

UNITED STATES OF AMERICA,

)

)

PLAINTIFF,

)

)

V.

)

)

PIEDMONT REGIONAL JAIL AUTHORITY, )

)

DEFENDANT.

)

Civil No.3: f 3- c..y-/:;k./6

SETTLEMENT AGREEMENT
I. INTRODUCTION
1. The Piedmont Regional Jail Authority ("Defendant"), and the United States of America (collectively, "the Parties") enter into this agreement ("Agreement") with the goal of ensuring that prisoners at the Piedmont Regional Jail ("Piedmont" or "Jail") are provided with constitutional medical and mental health care.
2. Through this Agreement, the Parties seek to ensure that prisoners' constitutional rights are protected. By providing for constitutional conditions at Piedmont, the Defendant will also provide for the safety of staff and promote public safety in the community.
3. The Civil Rights Division of the United States Department of Justice commenced an investigation of the conditions of confinement at the Piedmont Regional Jail after learning of a series of deaths at the jail. The United States of America, through the United States Department of Justice ("the United States"), notified the Piedmont Regional Jail Authority of its intention to investigate conditions of confinement at the Jail pursuant to the Civil Rights oflnstitutionalized Persons Act, 42 U.S.C. § 1997 ("CRIPA"). The United States' investigation included onsite interviews of Jail staff and prisoners, and a review of relevant Jail policies and procedures, reports, logs, and other relevant documents and data.
4. On September 6, 2012, the United States issued an investigative findings letter which concluded that certain conditions at the Jail violated the constitutional rights of prisoners detained or committed to the Jail ("Findings Letter") (attached as Appendix A). Specifically, the United States found a pattern or practice of constitutional violations in Piedmont's provision of medical care and mental health care.
5. From the beginning, and continuing throughout the United States' investigation of conditions of confinement at Piedmont, Defendant has pledged its cooperation to

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address concerns the United States has raised with respect to conditions at the Jail. This Agreement memorializes the actions that Defendant will implement to address the United States' findings related to medical care and mental health care.

6. This Agreement shall be filed in the United States District Court, Eastern District of Virginia, and shall resolve the United States' claims that Piedmont is in violation ofthe Eighth and Fourteenth Amendments to the Constitution in its operation and management of the Jail.

7. The Court has jurisdiction over this action pursuant to 28 U.S.C. §1331; 28 U.S.C. § 1345; and 42 U.S.C. § 1997. Venue is proper in this district pursuant to 28 U.S.C. § 1391(b).

8. The Agreement shall constitute the entire integrated Agreement of the Parties. Except for the United States' September 6, 2012, Findings Letter, no prior contemporaneous communications, oral or written, or prior drafts shall be relevant or admissible for purposes of determining the meaning of any provisions of the Agreement in this litigation or in any other proceeding.

II.

DEFINITIONS

As used in this Agreement, the following definitions apply:

a. "Piedmont" or "Jail" means the Piedmont Regional Jail in Farmville, Virginia, or any facility that is used to replace or supplement the Jail.

b. "Defendant" means the Piedmont Regional Jail Authority.

c. "United States" means the United States Department of Justice, including the Civil Rights Division and the United States Attorney's Office for the Eastern District of Virginia, which represents the United States in this matter.

d. "CNA" means Certified Nursing Assistant.

e. Consistent with, or in accordance with, the term "generally accepted correctional standards" means those industry standards accepted by correctional professionals or organizations in the relevant subject area.

f. "Corrections Officers" means those individuals employed by the Jail whose primary responsibility is to provide prison security or escort service.

g. "Effective Date" means the date the Agreement is signed and entered by the Court.

h. "Include" or "including" means "include, but not be limited to" or "including, but not limited to."

2

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i.

"LPN" means individuals licensed as Licensed Practical Nurses by the State of Virginia.

J.

"Monitor" means an individual jointly selected by both Parties to assess and report on

implementation of the Agreement.

k. "Prisoners" or "Prisoner" means one or more individuals detained at, or otherwise housed, held, in the custody of, or confined at Piedmont.

1.

"Psychiatrist" means a medical or osteopathic doctor licensed to practice medicine or

osteopathy in the State of Virginia, who has completed a residency in psychiatry in a

program accredited by the American Association of Medical Colleges or the American

Osteopathic Association.

m. "Psychotropic medication" means any medication prescribed by a physician that is used in the treatment of mental illness which exerts an effect on the brain and is capable of modifying mental activity or behavior.

n. "Qualified Health Professional" means a physician, physician assistant, nurse practitioner, registered nurse, or licensed practical nurse who is currently licensed by the State of Virginia and provides medical care and services to prisoners at Piedmont.

o. "Qualified Mental Health Professional" means a registered nurse with education and training in psychiatric nursing, or an individual with a minimum of a master's level degree and training in psychiatry, psychology, counseling, or social work. The Qualified Mental Health Professional must be currently licensed by the State of Virginia to deliver those mental health services he or she has undertaken to provide.

p. "Restraints" means restraints used for medical or mental health purposes, including, but not limited to, 4-point restraints and restraint chairs.

q. "RN" means Registered Nurse.

r.

"Serious Suicide Attempt" means any suicide attempt for which medical care is

required, or which requires or should require transfer to a higher level of care.

s. "Substantial Compliance" means that Defendant has achieved material compliance with each substantive provision of this Agreement and has maintained such compliance for 18 consecutive months, except for minor occasional aberrational violations. Material compliance requires that, for each provision, Piedmont has developed and implemented a policy incorporating the requirement, that relevant personnel have been trained on the policy, and that Piedmont is complying with the requirement in actual practice. For example, provisions requiring that specific policies be developed require also that the Jail train relevant personnel on the requirements of that policy, and that the Jail act in accordance with that policy. Similarly, provisions requiring that the Jail implement particular practices require also that that the requirement be incorporated into Jail policy.

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t.

"Suicide precautions" means any level of watch, observation, or measures to prevent

self-harm.

u. "Timely" means the provision of medical or mental health care consistent with generally accepted correctional standards of care, depending on the nature of the situation, such as emergency, urgent, or routine.

v. "Train" means to instruct in the noted skills to a level that the trainee has the demonstrated proficiency to implement those skills as and when called for. A person is "trained" if he or she is able to describe, demonstrate, and apply the noted skills.

III.

SUBSTANTIVE PROVISIONS

Piedmont shall achieve substantial compliance with the substantive provisions of this Agreement listed below. These provisions are intended to ensure that prisoners receive proper medical and mental health treatment and do not experience urmecessary suffering or harm while incarcerated. The failure to provide necessary treatment not only harms prisoners, but affects public safety if prisoners' health deteriorates during incarceration. Accordingly, the Jail shall ensure constitutionally adequate intake, assessment, treatment, and monitoring of prisoners with medical and mental health needs. The Jail's adoption of the substantive provisions in this Agreement will satisfy the fmdings made by the United States in its letter dated September 6,
2012.

A. Medical Care

Piedmont shall ensure that prisoners with medical conditions and/or injuries receive treatment appropriate to their condition and adequate to prevent urmecessary suffering or risk of harm. To achieve this outcome, Piedmont shall implement the requirements below.

1. Staffing

a. Piedmont shall ensure that the Jail's medical staffing is sufficient to provide adequate care for prisoners' needs, fulfill constitutional mandates and the terms of this Agreement, and allow for the adequate operation of the Jail, consistent with constitutional standards. Piedmont shall achieve adequate medical staffing in the following marmer:

(1) Within 180 days of the Effective Date, Piedmont shall ensure that there are at least 3.5 hours of physician time per week for every 100 prisoners, based on the highest monthly average census within the past three months. De minimis temporary deviations from this ratio will not necessarily result in a finding of non-compliance with this provision.
(2) Within 180 days ofthe Effective Date, Piedmont shall hire sufficient numbers of medical staffto provide adequate medical care. This medical staffing shall include at least one RN and six LPNs, provided the prisoner

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count remains below 600, and that all health assessments are completed in a timely marrner by either the physician or the RN. Ifthe prisoner count exceeds 600, Piedmont shall hire two additional LPNs. If health assessments are not being completed within 14 days, Piedmont shall hire one additional RN. (3) Once yearly thereafter during the term of this Agreement, Piedmont shall perform a medical staffing analysis, which it shall submit to the Monitor and DOJ for review and approval. If that analysis demonstrates that staffing ratios need to be increased to provide constitutionally adequate medical care, Piedmont shall increase staffing as necessary to ensure constitutional medical care.
b. Piedmont shall ensure that all persons providing medical treatment meet applicable state licensure and/or certification requirements, and practice only within the scope of their training and licensure.
c. CNAs shall not perform any tasks beyond support functions (e.g., taking vital signs, prepping patient charts, etc.).
d. Corrections Officers shall not provide any type of non-emergency medical care, and clear guidelines shall be in place for any individuals providing clinical support, with physician oversight.
2. Policies
a. Piedmont shall revise its policies and procedures to establish clear direction and expectations for all staff.
b. Piedmont shall create and adopt policies consistent with the 2008 National Commission on Correctional Health Care ("NCCHC") Jail Standards. At minimum, Piedmont shall draft policies consistent with those standards deemed essential by the NCCHC. NCCHC essential standards include:
• Access to Care • Responsible Health Authority • Medical Autonomy • Administrative Meetings and Reports • Policies and Procedures
• Continuous Quality Improvement Program
• Emergency Response Plan • Communication on Patients' Health Needs
• Infection Control Program
• Credentialing • Professional Development
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• Health Training for Correctional Officers
• Medication Administration Training • Inmate Workers
• Pharmaceutical Operations
• Medication Services • Information on Health Services
• Receiving Screening • Transfer Screening
• Initial Health Assessment • Mental Health Screening and Evaluation
• Oral Care
• Nonemergency Health Care Requests and Services • Emergency Services • Segregated Inmates • Continuity of Care During Incarceration • Chronic Disease Services • Patients with Special Health Needs • Infirmary Care (currently inapplicable, but to be adopted should Piedmont
construct an infirmary) • Basic Mental Health Services • Suicide Prevention Program • Intoxication and Withdrawal • Care of the Pregnant Inmate • Health Record Format and Contents • Confidentiality of Health Records • Restraint and Seclusion (currently inapplicable, but to be adopted should
Piedmont begin using restraints and seclusion) • Emergency Psychotropic Medication
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3. Intake Screening

a. Piedmont shall ensure that the medical screening aspect of the initial intake screening is performed by a Qualified Health Professional.

b. Piedmont shall ensure that all initial screenings are fully documented and available to medical staff in each prisoner's medical file.

c. Piedmont shall ensure that it adopts policies consistent with applicable professional standards providing guidance for when prisoners should be referred to a physician after initial screening.

4. Chronic Care

Piedmont shall promulgate and implement a policy establishing a chronic care program

with disease-specific clinical guidelines that does the following:

1.

defines illnesses that qualify for inclusion in the program;

ii. ensures that prisoners with chronic care issues are

identified and examined by the physician;

111. tracks prisoners in the program;

IV. schedules periodic assessments;

v. provides for diagnostic tests at an initial comprehensive

visit;

vt. malces lab work available at appointments in order to

determine the status of disease control; and

vn. outlines a clinical plan for each chronically ill prisoner.

5. Health Assessments

Piedmont shall develop and implement a system to provide each prisoner with a comprehensive health assessment, conducted by a physician, physician assistant, nurse practitioner, or registered nurse under the supervision of a physician, within fourteen days of arrival. Piedmont shall ensure that any prisoner whose health assessment identifies a medical problem is referred to the physician for follow-up care.

6. Sick Call

a. Piedmont shall establish nursing protocols, signed by the medical director, for use during sick call, that will allow nurses to properly triage prisoners' medical needs and ensure that prisoners are referred for, and provided with, appropriate treatment in a timely manner. These protocols should address common symptoms, and should instruct nurses about the questions they should ask of prisoners with those symptoms, and the objectives they should accomplish in evaluating those prisoners.

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b. Piedmont shall ensure that the physician provides oversight of the sick call process through a monthly review of the nurses performing sick call, in order to ensure that personnel are not practicing beyond their training. The review shall determine whether nurses are providing appropriate care and whether they are following facility policy and procedure.

7.

Correctional Staff Training

a. Piedmont shall ensure that all officers are trained armually in providing first-responder medical care, and that all medical and security staff are basic cardiac life support ("BCLS")-certified. Piedmont shall submit the curriculum for these trainings to the Monitor and DOJ for review and approval prior to delivering this training.

b. Piedmont shall develop and implement comprehensive training on suicide prevention and mental health care, including an introductory training provided to new hires as well as armual in-service training, which will include training on basic mental health information (e.g., recognizing mental illness, specific problematic behaviors, additional areas of concern); identification, timely referral, and proper supervision of prisoners with serious mental health needs; appropriate responses to behavior symptomatic of mental illness; suicide prevention; and an armual refresher training on relevant topics. The training shall be conducted by Qualified Mental Health Professionals. The curriculum shall be submitted to the Monitor and DOJ for review and approval prior to delivery of the training.

8. Co-Pays

a. Piedmont shall exclude from co-payments all health care required by the Jail, including health assessments and mental health care, as well as necessary medical care, including chronic care and emergency visits.

b. Piedmont shall require only one co-payment fee to see a nurse, with no further fee assessed ifthe prisoner is referred to the doctor for further evaluation.

c. If follow-up care for a serious medical need is clinically indicated, no copayment shall be required for that care, nor will a prisoner be charged multiple co-payments if he or she receives care more than one time during any 30-day period for the same serious medical need.

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d. Piedmont shall not require a co-payment for health care if the co-payment would result in effectively denying care to the prisoner by dissuading the prisoner from seeking needed health care. For the purposes ofthis Agreement, the Parties have established the following co-payment schedule (subject to change to conform with Virginia law, provided that the Monitor and DOJ are informed of any changes and that the changes are constitutionally adequate) and have agreed that this co-payment shall be waived if it would cause the balance in a prisoner's account to go below $5.00. Co-Payment Schedule: $2.00 to see a nurse; $3.00 to see a doctor; and $8.00 for an emergency visit (i.e. visit on an expedited basis) if it is determined that an expedited visit was medically unnecessary.
B. Mental Health Treatment
Piedmont shall ensure that prisoners suffering from mental illness receive treatment appropriate to their condition and adequate to prevent unnecessary suffering or risk of harm. Proper treatment will also assist prisoners in successfully reentering the community upon release. To achieve this outcome, Piedmont shall implement the requirements below.
1. Mental Health Staffing
Piedmont shall ensure that the Jail's mental health staffing is sufficient to provide adequate care for prisoners' serious mental health needs, fulfill constitutional mandates and the terms of this Agreement, and allow for the adequate operation of the Jail, consistent with constitutional standards. Piedmont shall achieve adequate mental health staffing in the following manner:
(l) Within 180 days of the Effective Date, Piedmont shall ensure that the Jail meets the following staffmg level for Qualified Mental Health Professionals: Piedmont shall employ a full-time QMHP and a Psychiatrist who is onsite at the Jail no less than once per week for a number of hours sufficient to provide adequate medical care, provided that telemedicine and further in-person assessments will otherwise be provided by the Psychiatrist where clinically indicated.
(2) Beginning one year after the Effective Date, and then continuing once yearly thereafter during the term of this Agreement, Piedmont shall perform a mental health staffing analysis, which it shall submit to the Monitor and DOJ for review and approval. If that analysis demonstrates that staffing ratios need to be increased to provide adequate mental health care, Piedmont shall increase staffing as necessary to ensure constitutional mental health care.
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2. Mental Health Policies

Piedmont shall implement comprehensive policies and protocols to ensure that the Jail delivers mental health services that are adequate in quality and array, as provided for in the NCCHC Jail Standards related to mental health care. These policies and protocols must require a treatment plan for prisoners with serious mental illness and contain mechanisms sufficient to measure whether care is being provided in a manner consistent with the Constitution. The policies and protocols shall:

a. Ensure that all prisoners are appropriately screened for mental illness using an appropriately validated screening instrument.

b. Ensure that all prisoners with a known or suspected mental illness are referred to the psychiatrist within 14 days of arrival, and that individuals with more acute needs are seen and treated as soon as Piedmont becomes aware of their
condition.

c.

Ensure that prisoners with chronic mental illness are placed on a chronic mental

health list for follow-up every 30, 60, or 90 days, as clinically appropriate.

Prisoners with chronic mental illnesses shall not be required to submit a request

for mental health services in order to receive such services at regular intervals.

d. Ensure that prescriptions for psychotropic medications are reviewed by a psychiatrist on a regular, timely basis to assess whether each prisoner's prescribed regimen continues to be appropriate and effective for his or her condition. Whenever a psychotropic medication is discontinued, added, or changed, Piedmont will ensure that the psychiatrist or other qualified prescriber making such changes contemporaneously documents the reason for such change
in the prisoner's health record.

e. Ensure that individuals receiving psychotropic medication are adequately monitored for potential negative side-effects of such medications, and that prisoners on such medications are evaluated by the psychiatrist within two weeks
of starting any new medication.

3. Suicide Prevention

Piedmont shall implement comprehensive policies and protocols to ensure that prisoners at risk of self harm are identified, protected, and treated in a manner consistent with the Constitution. Piedmont shall continuously track and analyze prisoners' risk of self harm and implement measures to protect prisoners by reducing or eliminating the risk of harm. The policies and protocols shall:

a. Protect the safety of prisoners at risk for self-injurious behavior or suicide by providing timely and adequate access to Qualified Mental Health Professionals.

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b. Ensure that prisoners on suicide watch are provided with the appropriate level of supervision. Actively suicidal prisoners shall be placed on constant observation, while potentially suicidal prisoners shall be monitored at staggered intervals not to exceed every 15 minutes. Correctional Officers shall document their checks in a format that does not have pre-printed times and staff shall document their visual verification of the prisoners' welfare accurately and completely. A supervisor shall conduct and document a review of all documents related to this provision before the end ofthe shift during which it occurred to ensure compliance with policy and this Agreement.

c. Ensure that all staff who have contact with prisoners have ready access to cutdown tools and are trained to use them effectively.

d. Ensure that a Qualified Mental Health Professional regularly, but no less than once per shift, reassesses prisoners on suicide precautions to determine whether the level of precaution or supervision should be raised or lowered. These reassessments shall be documented and recorded in the prisoners' medical charts. If no Qualified Mental Health Professional is present, the facility physician should provide such monitoring.

C. Quality Assurance

Piedmont shall develop, implement, and maintain a system to ensure that trends and incidents involving deficiencies in medical and mental health care are identified and corrected in a timely manner.

a. Within 180 days of the Effective Date, Piedmont shall develop and implement written Quality Assurance policies and procedures adequate to identify and address serious deficiencies in medical and mental health care, including sick call, health assessments, intake, chronic care, medication administration, emergency care, and infection control.

b. Within 180 days of the Effective Date, Piedmont shall implement monthly quality assurance mechanisms at the individual and system levels to prevent or minimize harm to prisoners. These quality assurance mechanisms shall track and analyze patterns and trends regarding the provision of medical and mental health care at Piedmont. Each monthly report shall include:

(1) relevant aggregate data, including:

1.

the time elapsed between prisoners' requests for medical or

mental health services and the provision of services by a Qualified

Health Professional or Qualified Mental Health Professional,

separated by the following categories:

i. nurse sick call;

ii. physician referral;

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11. m.
IV.
v. vi.
v11. vm.
IX.
x. xt. xii. xm.
XIV.
xv. xvt. xvn.
xvm. xix. xx. xxi.

111. psychiatrist referral; the number of health assessments performed and how many were reviewed by the physician, if performed by a registered nurse; a list of prisoners with chronic medical or mental illnesses, separated by disease or condition, and including the dates prisoners were treated by a Qualified Health Professional or Qualified Mental Health Professional; the number of prisoners sent to outside facilities for inpatient care, as well as the condition of each prisoner at the time he or she was sent to the outside facility; the number of prisoners sent for specialty consultation, with the specialty service identified for each individual prisoner; the number of prisoners sent to the emergency room and the number admitted, with the reason admitted and the clinical outcome for each prisoner, as well as the reasons not admitted for those prisoners who were not admitted; the number of prisoners being treated for HIV; the number of prisoners pregnant and the number referred for obstetrics services; the number of prisoners who are PPD positive and the number of chest x-rays performed to assess for tuberculosis; the number of prisoners treated for possible substance abuse withdrawal, with clinical outcomes listed; the number of prisoners prescribed psychotropic medications; the number of prisoners prescribed two or more psychotropic medications; the average amount of time between visits with a Qualified Mental Health Professional for prisoners on psychotropic medications; the number of prisoners placed on suicide watch; the average length of time prisoners are kept on suicide watch; the number of times restraints were used; for medical and mental health staff, the vacancy report with positions and days vacant, and the number of applicants for each position; a list of new hires and terminations for medical and mental health staff; a list of all medical and security staff whose BCLS certifications will expire in the next two months; a list of all medical and security staff who have undergone any training required under this Agreement; and the number of hours oftraining each staff member receives on suicide prevention and mental health matters each year.

(2) an assessment of trends and interventions, including:

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1.

the timeliness of medical and mental health services provided;

ii.

referrals to outside care;

m.

whether prisoners with chronic medical and mental illnesses are

receiving services at regular intervals without requesting such

services, as measured by tracking logs;

iv.

whether prisoners are receiving appropriate and adequate mental

health counseling and therapy;

v.

whether all concerns or deficiencies identified through the Quality

Assurance process have been addressed through a corrective

action plan, and what findings have been made under that plan;

vi.

a review of any policies revised or developed as a result of any

deficiencies identified through the Quality Assurance process;

vn.

whether Quality Assurance audit tools have been developed for

all provisions in this Agreement and performed monthly; and

vm.

the effectiveness of interventions undertaken in response to

identified trends from previous months.

c. Based on these monthly assessments, Piedmont shall recommend and implement changes to policies and procedures.

d. All monthly reports shall be provided to the Monitor, who will closely review the reports and consider them when determining whether constitutional care is being provided or whether any changes need to be made to policies and procedures.

e. The Jail shall ensure that all relevant facts and circumstances surrounding deaths are investigated and reviewed by a multidisciplinary team, consisting of medical, mental health, and corrections staff. This team shall identify any areas in which staff performance could be improved or jail procedures could be adjusted to improve the ability to provide care to prisoners. All reviews shall be documented and shall include the team's findings, concerns, recommendations
and remedial actions.

IV. REPORTING REQUIREMENTS AND RIGHT OF ACCESS

A. Unless a different period is provided elsewhere in the Agreement, within 180 days of the Effective Date, Piedmont shall revise and/or develop as necessary other written documents such as screening tools, logs, handbooks, manuals, and forms, to effectuate the provisions of this Agreement. Piedmont shall send newly-drafted and revised policies and procedures to the United States and the Monitor for review and approval as they are promulgated. The United States reserves the right to withhold consent to any policies or procedures that are inconsistent with this Agreement. The United States will not unreasonably withhold approval. Ifthe United States withholds consent, Piedmont will re-submit revised policies or procedures to the United States within 14 days of its receipt of notice of the withholding of consent from the United States. When disputes arise regarding policies and procedures, the United States may initiate judicial enforcement proceedings subject to the aforementioned 14-day cure period. Piedmont

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shall provide initial and in-service training to all facility staff with respect to newly implemented or revised policies and procedures. Piedmont shall document employee review and training in policies and procedures. On an annual basis, Piedmont shall review all policies and procedures and submit them to the Monitor and the United States for review and approval.
B. Piedmont shall file with the Court bi-annual compliance reports, the first of which shall be filed within 180 days of the date of the Effective Date. Thereafter, the bi-annual reports shall be filed 15 days after the termination of each six-month period until this Agreement is terminated. The report shall surumarize Quality Assurance activities and capture data that is tracked and monitored under the monthly reporting provisions.
C. Piedmont shall within 24 hours notifY the Monitor and the United States upon the death of any prisoner, and upon any serious suicide attempt. Piedmont shall forward to the Monitor and the United States incident reports and medical and/or mental health reports related to deaths, autopsies, and/or death surumaries of prisoners.
D. Each compliance report shall describe the actions Piedmont has talcen during the reporting period to implement this Agreement and shall make specific reference to the Agreement provisions being implemented.
E. Piedmont shall maintain sufficient records to document that the requirements of this Agreement are being properly implemented and shall make such records available to the United States within two business days for inspection and copying. In addition, Piedmont shall maintain and provide, upon request, all 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, investigations, and incident reports).
F. The United States and its attorneys, consultants, and agents shall have unrestricted access to the Jail, prisoners, staff, information, and documents as reasonably necessary to verify the Jail's substantial compliance with this Agreement.
V. MONITORING
A. Monitor Selection: The Parties have jointly selected James Welch to serve as the Monitor overseeing implementation of the Agreement. Should the monitor position become vacant and if the Parties cannot agree on a replacement, the Parties shall recommend candidates to the Court, and the Court will appoint the Monitor from the names submitted by the Parties. Neither Party, nor any employee or agent of either Party, shall have any supervisory authority over the Monitor's activities, reports, findings, or recommendations. The cost for the Monitor's fees and expenses shall be borne by Defendant. The selection of the Monitor shall be conducted solely pursuant to the procedures set forth in this Agreement, and will not be governed by any formal or legal procurement requirements. The Monitor may be terminated only for good cause,
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unrelated to the Monitor's findings or recommendations, and only with prior notice to, and approval of, the Parties acting jointly or by Court order. Should the Parties agree that the Monitor is not fulfilling his or her duties in accordance with this Agreement, 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 Party will have the opportunity to respond to the petition.
B. Monitor Qualifications: The Monitor shall be an individual of the highest ethics, and shall have appropriate experience and education or training related to the subject areas covered in this Agreement.
C. Monitor Access: The Monitor shall have full and complete access to the Jail, all Jail records, prisoner medical and mental health records, staff, and prisoners in order to assess the Jail's substantial compliance with this Agreement. Defendant shall direct all employees to cooperate fully with the Monitor. All non-public information obtained by the Monitor shall be maintained in a confidential manner.
D. Monitor Ex Parte Communications: The Monitor shall be permitted to initiate and receive ex parte communications with the Parties and the Court.
E. Limitations on Public Disclosures by the Monitor: Except as required or authorized by the terms of this Agreement or the Parties acting together, the Monitor shall not: make any public statements (at a conference or otherwise) or issue findings, except as required under paragraph F, listed below, with regard to any act or omission of Defendant or its agents, representatives, or employees, or disclose nonpublic information provided to the Monitor pursuant to this Agreement. Any press statement made by the Monitor regarding the monitoring of this Agreement or his or her employment as Monitor must first be approved in writing by the Parties. Unless required by law, the Monitor shall not testifY in any other litigation or proceeding with regard to any act or omission of Defendant or any of its agents, representatives, or employees related to this Agreement, nor testifY regarding any matter or subject that he or she may have learned as a result of his or her performance under this Agreement. Reports issued by the Monitor shall not be admissible against Defendant in any proceeding other than a proceeding related to the enforcement of this Agreement by Defendant or the United States. Unless such conflict is waived by the Parties, the Monitor shall not accept employment or provide consulting services that would present a conflict of interest with the Monitor's responsibilities under this Agreement, including being retained (on a paid or unpaid basis) by any current or future litigant or claimant, or such litigant's or claimant's attorney, in connection with a claim or suit against Defendant, its departments, officers, agents, or employees. The Monitor is not a State/County or local agency or an agent thereof, and accordingly the records maintained by the Monitor shall not be deemed public records subject to public inspection. Neither the Monitor nor any person or entity hired or otherwise retained by the Monitor to assist in furthering any provision of this Agreement shall be liable for any claim, lawsuit or demand arising out of the Monitor's performance pursuant to this Agreement. This provision does not apply to any
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proceeding before a court related to performance of contracts or subcontracts for monitoring this Agreement.

F. Monitor's Reports: The Monitor shall file with the Court and provide the Parties with reports describing the steps taken by Defendant to implement this Agreement and evaluate the extent to which Defendant has complied with each substantive provision of the Agreement. In the report, the Monitor shall also evaluate whether Defendant's compliance with the substantive provisions of the Agreement has resulted in the achievement of the Agreement's goal of providing constitutional health care. The Monitor shall issue an initial report 120 days after Defendant file its first compliance report, and then every 180 days thereafter. The reports shall be provided to the Parties in draft form for comment at least 14 days prior to their issuance. These reports shall be written with due regard for the privacy interests of individual prisoners and staff and the interest of Defendant in protecting against disclosure of non-public information.

G. Assessing Compliance with Goals of Agreement: In order to assess Defendant's progress toward achieving the Agreement's goal of ensuring that Piedmont provides prisoners with constitutional health care, within 120 days of appointment the Monitor shall develop qualitative and quantitative outcome measures, to be approved by the Parties. These outcome measures may include the data contained in Defendant's monthly quality assurance reports, as well as other relevant data, that assist the Monitor, the Parties, and the Court in evaluating the constitutionality of Piedmont's medical and mental health treatment. The Monitor shall include the outcome measures used, the data relied upon, and the Monitor's ultimate conclusions, based on its analysis of those
outcome measures, in the Monitor's report.

H. Assessing Compliance with Agreement Provisions: In the Monitor's report, the Monitor shall evaluate whether Piedmont has attained material compliance with each provision of this Agreement. In order to assess compliance, the Monitor shall review a sufficient number of pertinent documents to accurately assess current condition and shall interview all necessary staff and prisoners. The Monitor shall also communicate with exprisoners, family members, and relevant community members to assist the Monitor's assessment of current conditions. The Monitor shall be responsible for independently verifying representations from Defendant regarding progress toward compliance and examining supporting documentation. Each Monitor's report shall describe the steps taken by the Monitor to analyze conditions and assess compliance, including documents reviewed and individuals interviewed, and the factual basis for each of the Monitor's
findings.

I.

Periodic Review of Agreement: The Monitor shall also review the provisions of the

Agreement and assess whether any Agreement provision as drafted is not furthering the

purpose of the Agreement or whether there is a preferable alternative that will achieve

the same purpose. If so, the Monitor shall identifY such provisions to the Parties.

Where the Parties or the Monitor are uncertain whether a change to the Agreement is

advisable, the Parties may agree to suspend the current Agreement requirement for a

time period agreed upon at the outset ofthe suspension. During this suspension, the

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Parties may agree to temporarily implement an alternative requirement. The Monitor shall assess whether the suspension of the requirement, and the implementation of any alternative provision, is as or more effective at achieving the purpose ofthe original Agreement requirement and the Parties shall consider this assessment in determining whether to jointly stipulate to make the suggested change, modification, or amendment. The Parties shall then confer and submit any proposed modifications to the Court for its approval.
J. Availability of Reports: The Defendant agrees to make the Monitor's Final Reports, which are filed with the Court, publicly available by electronic means on the Piedmont Regional Jail's website within 10 business days after the Reports are filed.
K. Compliance Coordinator: The Parties agree that Piedmont will assign a current employee to serve as the Piedmont Compliance Coordinator for the duration of this Agreement. The Compliance Coordinator will serve as a liaison between the Defendant and the Monitor and will assist with the Defendant's compliance with this Agreement. At a minimum, the Compliance Coordinator will: coordinate the Defendant's compliance and implementation activities; facilitate the provision of data, documents, materials, and access to the Defendant's personnel to the Monitor, the United States, and the public, as needed; ensure that all documents and records are maintained as provided in this Agreement; and assist in assigning compliance tasks to Piedmont personnel, as directed by the Superintendent or his designee. The Compliance Coordinator will take primary responsibility for collecting information the Monitor requires to carry out the duties assigned to the Monitor.
L. Monitor's Budget: Defendant shall provide the Monitor with a budget sufficient to allow the Monitor to carry out the responsibilities described in this Agreement.
M. Technical Assistance by the Monitor: The Monitor shall provide Defendant with requested technical assistance as consistent with its responsibilities as Monitor. Technical assistance should be reasonable and should not interfere with the Monitor's ability to assess compliance.
VI. ENFORCEMENT
A. During the period that the Agreement is in force, ifthe Monitor or the United States determines that Defendant is not in substantial compliance with the Agreement, and such failure constitutes a violation of prisoners' constitutional rights, the United States may initiate contempt or enforcement proceedings for an alleged failure to fulfill an obligation under the Substantive Provisions of this Agreement in Court subject to the cure provisions set forth in this Section VI.
B. Prior to taking judicial action to initiate contempt or other enforcement proceedings, the United States shall give Defendant written notice of its intent to initiate such proceedings, and the Parties shall engage in good-faith discussions to resolve the
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dispute. The written notice from the United States to the Defendant shall itemize each alleged failure to fulfill an obligation under the Substantive Provisions of the Agreement to allow Defendant to remedy the alleged deficiencies.
C. Defendant 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 the United States 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 the United States reasonably determines that the failure has not been cured, the United States may initiate contempt proceedings without further notice. The United States agrees to work in good faith with Defendant to avoid enforcement actions.
D. In case of an emergency posing an immediate threat to the health or safety of any prisoner or staff member at the Jail, however, the United States may omit the notice and cure requirements and seek immediate enforcement of the Agreement.
VII. CONSTRUCTION, IMPLEMENTATION, AND TERMINATION
A. The implementation of this Agreement can begin at any time but shall begin no later than the Effective Date.
B. Except where otherwise agreed to under a specific provision of this Agreement, Defendant shall implement all provisions of this Agreement within 180 days of the Effective Date.
C. The Court shall retain jurisdiction of this action for all purposes until Piedmont has achieved substantial compliance with each provision of the Agreement, provides constitutional medical and mental health care to prisoners, and has maintained substantial compliance and provided constitutional medical and mental health care for a period of 18 months. If both Parties agree that substantial compliance has been maintained, and constitutional medical and mental health care has been provided, for a period of 18 months, the Parties will jointly stipulate to dismissal of the case within 30 days.
D. Failure by any Party to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of its right to enforce other deadlines or provisions of this Agreement.
E. If any unforeseen circumstance occurs that causes a failure to comply with any requirements of this Agreement in a timely manner, Defendant shall notify the United States in writing within five days after Defendant becomes aware ofthe unforeseen circumstance and its impact on the Defendant's ability to perform under the Agreement. The notice shall describe the cause of the failure to perform and the measures taken to
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prevent or minimize the failure. Defendant shall implement all reasonable measures to avoid or minimize any such failure.

F. The Agreement shall be binding upon the Parties and their successors, and applicable to acts of their officers, agents, employees, and assigns.

G. Each Party shall bear the cost of its fees and expenses incurred in connection with this cause.

H. If any provision of this Agreement is declared invalid for any reason by a court of competent jurisdiction, said finding shall not affect the remaining provisions of this Agreement.

I.

No person or entity is intended to or shall be a third-party beneficiary of the provisions

of this Settlement Agreement for purposes of any civil, criminal, or administrative

action, and accordingly, no person or entity may assert any claim or right as a

beneficiary or protected class under this Settlement Agreement. This Settlement

Agreement is not intended to impair or expand the right of any person or organization to

seek relief against Piedmont, its employees, or agents for their past or future conduct;

accordingly, this Agreement does not alter any legal standards governing any such

claims, including those under any federal or Virginia law.

J. The Parties agree that litigation in this matter is not reasonably foreseeable or anticipated. Accordingly, the Parties agree that they are not obligated to preserve potentially discoverable information.

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

The Parties stipulate that this Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a). The Parties further stipulate and agree and the Court finds that the prospective relief in this Agreement is narrowly drawn, extends no further than necessary to correct the violations of federal rights as set forth by the United States in its Complaint and Findings Letter, 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 Agreement complies in all respects with the provisions of 18 U.S.C. § 3626(a).

tJt,:I).I~L, Respectfully submitted, this.Z.O day of

ZolJ ,

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KATHLEEN M. KAHOE ACTING UNITED STATES ATTORNEY
ByRIWJJJJk
Robert P. Mcintosh Virginia Bar Number 66113 Assistant United States Attorney United States Attorney's Office 600 East Main Street, Suite 1800 Richmond, Virginia 23219 Telephone: (804) 819-5400 Facsimile: (804) 819-7417 Email: Robert.Mclntosh@usdoj.gov

FOR THE UNITED STATES:
\ \
ROY L. AUSTIN, Deputy Assistant Attorney General Civil Ri ht Divi ·on
SMITH
Special Litigation Section
~ Deputy Chief Special Litigation Section
~ ./. ;z-~
AARON S. FLEISHER Trial Attorney Special Litigation Section Civil Rights Division U.S. Department of Justice 950 Pennsylvania Avenue, NW PHB 5912 Washington, DC 20530 Telephone: (202) 307-6457 Facsimile: (202) 514-6903 Email: aaron.fleisher@usdoj.gov

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FOR THE PIEDMONT REGIONAL JAIL AUTHORITY: Chairman, Board of Directors, Piedmont Regional Jail
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APPENDIX
A

Case 3:13-cv-00646-JRS Document 3-2 Filed 09/20/13 Page 23 of 41 PageID# 62 U. S. Department of Justice

Asststam /i.rtorm.y General

HitshingtmJ, D, C. 20530
SEP - 6 201Z

VIA U.S. MAIL
Mr. James Garnett Chairman, Board of Directors Piedmont Regional Jail 801 lndustrial Road Farmville, VA 23901
Re: lnvestigation ofPiedmont Regional Jail. pursuant to the Civil Rights of lnstitutionalized Persons Act, 42 U.S.C. § 1997. and the Religious Land Use and Institutionalized Person§ Act of2000 {"RLUIPA")
Dear Mr. Garnett:
The Civil Rights Division of the United States Department of Justice has concluded its investigation of conditions at the Piedmont Regional Jail ("Piedmont," "the Facility," or "the Jail"), pursuant to the Civil Rights oflnstitutionalized Persous Act, 42 U.S.C. § 1997 ("CRIPA"), and the Religious Land Use and lnstitutionalized Perseus Act of2000 ("RLUIPA").
Our investigation found reasonable cause to believe that the Jail is denying necessary medical and mentul health care, and consequently places prisoners at an unreasonable risk of serious harm, in violation ofthe Constitution. These lapses, ifnot correeted, have a likelihood of resulting in nanecessary injury end/or loss of life. By implementing the corrective measures set forth below, the Jail will fulfill its duty to protect the health end safety of those in its cnstody.
We also found that the Jail does not currently violate RLUIPA During our tour, we identified practices that.rnay have created a substuntial burden on the religious exercise of prisonera. The Jail immediately made changes in response to our recommendations that resolved the issue.
During our exit briefmg, the Piedmont leadership expressed a desire and intent to rectify any problems identified by the investigation. We look forward to discussing our fmdings with you after you have had the opporronity to review this letter. The Jail is an integral part of the public safety system. The remedies we propose will ensure respect for the rights of prisoners

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confined there and will also provide for the safety of staff and promote public safety in the community.
I. Investigation
On March 4, 2011, we notified you that we were opening an investigation of Piedmont pursuant to CRIPA and RLUIPA. Our initial inquiry was prom~ted, in part, by a series of allegedly preventable deaths in the Jail between 2006 and 2009. We learned from our inquiry that the circumstances of some ofthese deaths indicated a possible pattem of deliberate indifference to prisoners' serious medical needs and we thus opened a fom1al investigation. In addition, we had received information that Piedmont was placing undue burdens on Muslim prisoners' ability to observe the tenets of their religion.
We requested and reviewed documents provided by Piedmont and, ou June 16-17, 2011, we conducted an onsite inspection of the Jail. During our onsite inspection, we were accompanied by a correctional medical care consultant. We toured the Facility, observed Facility processes, interviewed staff and prisoners, and reviewed an array of doclllllents, including policies, procedures, and medical records. Consistent with our pledge of transparency, and to provide technical assistance where appropriate, we conveyed our prelinlinary determinations to Piedmont administrators during a telephonic exit presentation following our onsite visit. We conducted a brieffollow-up site-visit on March 6, 2012.
Piedmont leadership was cooperative and professional throughout our investigation. We are particularly grateful to Superintendent Ernest Toney and the entire Piedmont staff. Piedmont has provided ns with access to prisoner records and personnel, and responded to our requests before, during, and after our onsite visit in a transparent and forthcoming manner. We also appreciate Piedmont's receptiveness to our consultant's onsite and post-tour recommendations, and note that the Piedmont administration has, to date, consistently followed through on its expressed commitment to working with the United States to provide prisoners with reasonably safe and humane conditions of confinement, as required by the Constitution.
IT. Background
Piedmont is a minimum to high-secnrity facility located in Farmville, Virginia, situated between the cities ofRiclnnond and Lynchburg. The Jail serves six counties (Amelia, Buckingham, CUlllberlaod, Lnnenburg, Nottoway, and Prince Edward), and is administered by a board consisting of two members from each connty. The current Supe~.~ntendent of the Jail is Ernest Toney.
Piedmont opened in 1988 with capacity for approximately 100 prisoners, but has expaoded over the years. The Jail's capacity is now approximately 800, and at the time of our onsite tour, there were approximately 660 prisoners housed at Piedmont Piedmont houses pretrial detainees and convicted prisoners.
It is our understanding that after the last death during this time period, the U.S. Immigration and Customs Enforcement ("ICE~~) concluded that medical practice at Piedmont \vas below accepted community standards, and determined that the Facility could no longer be used to house ICE detainees.

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III. Findings
We find that deficiencies in the medical and mental health care provided to prisoners at Piedmont place prisoners at a snbstantial risk of serious harm. We further find that, during our investigation, the Jail acknowledged and began respecting the religious rights of all prisoners. Our findings are detailed below.
A. Medical Care at Piedmont Is Deficient and Creates Substantial Risks
Piedmont's system for the delivery of medical services places prisoners at an unreasonable risk of hmm. The Eighth Amendment affords convicted prisoners protection from cmel and unusual punishment. U.S. CONST. atnend. VIII. The constitntional rights of pre-trial detainees are guaranteed by the Fourteenth Amendment, which, the Supreme Court has consistently held, provides protection at least equal to the Eighfu Amendment. Bell v. Wolfish, 441 U.S. 520, 545 (1979). The Eighfu Amendment requires prison officials to "provide prisoners wifu adequate food, shelter, clothing, and medical care." Smith v. Davis, No. 7: 10-cv00263, 2011 WI. 3880944 (W.D. Va. Sept. 1, 2011) (citing Farmer v. Brennan, 511 U.S. 825, 832 (1994)).
The Constitution protects prisoners not only against ongoing harms, but also against the risk of future harm. Helling v. McKinney, 509 U.S. 25, 33 (1993) ("That the Eighth Amendment protects against future hmm to inmates is not a novel proposition . . . . It would be odd to deny an injunction to inmates who plainly proved an unsafe, life-threatening condition in their prison on the ground that nothing yet had happened to them."). Conditions posing a substantial1isk of serious harm to prisoners therefore violate the Constitution, even ifno prisoner has suffered actual harm at the time the violation is found. See Farmer, 511 U.S. at 845-47; Helling, 509 U.S. at 35 (finding fuat risk offutnre harm to prisoner's health stated a cause of action under the Eighth Amendment); Harden v. Green, No. 01-6393, 27 Fed. App'x. 173, 177 (4th Cir. 2001) (noting that the Eighth Amendment "embraces the treatment of medical conditions which may cause future health problems"). The Supreme Court has clearly stated that "a remedy for unsafe conditions need not await a tragic event" Helling, 509 U.S. at 33.
Many ofthe lapses we identify below are directly related to Piedmont's inadequate medical staffmg. There is too little onsite coverage by properly licensed staffmembers, forcing certified nursing assistants (CNAs) to practice and provide medical care beyond their training and licensure. The lack of sufficiently trained and available medical staff for the management and evaluation of serious medical conditions places prisoners at risk ofmmecessary hrum and is deliberately indifferent to prisoners' serious medical needs. Plison officials, including doctors, "violate the civil rights ofimnates when they display 'deliberate indifference to serious medical needs."' Gordon v. Kidd, 971 F.2d 1087, 1094 (4th Ci:r. 1992) (citing Estelle v. Gamble, 429 U.S. 97, 104 (1976)). l'lison officials knowingly disregard, or act with deliberate indifference to, prisoners' rights by "intentionally denying or delaying access to medical care or intentionally interfering with the treatnlent once prescribed." Smith v. Smith, 589 F.3d 736, 738-39 (4th Cir. 2009) (citing Estelle, 429 U.S. at 104-05). Officials also violate the Constitution when they are deliberately indifferent to "an unreasonable risk of serious dan1age to ... [a prisoner'sJ future health." Heiling, 509 U.S. at 35.

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1. Piedmont exposes prisoners to risk ofharm by relying on unqualified staffto peiform essentinl medicalfunctions.
Perhaps 1he most significant single concern we have with ihe provision ofmedical and mental health care at the Facility is ihat staffmembers routinely perform medical services beyond what they are trained and credentialed to do. Piedmont's failure to ensure properly trained and credentialed staffing is to be expected, given its physician's indifference to such standards: while testifying under oaih in March 2012, he stated that he was not aware ofihe staffmg standards mandated by Virginia regarding medical staff at correctional facilities. Our finding is also consistent wiih ihe findings of oilier experts and inspecting bodies, who have made similar findings in recent reviews of Piedmont's medical services.
The Facility has one physician and two Licensed Professional Nurses (LPNs). The lead LPN is the primary liaison for medical services at ihe Jail. The rest of the medical staff consists of eight CNAs, and one mental healih counselor. CNAs are not nurses, and must not be substituted for nursing staff. Per ihe Virginia Nursing Board, CNAs cannot be used to perform ihe following: activities involving nursing assessment, problem identification, or outcome evaluation reqniling independent nursing judgment; coordination or management of care involving collaboration, consultation and referral; and emergency and nonemergency triage.
Despite these prohibitions, CNAs perform many ofihese tasks at Piedmont, including receiving
verbal medication orders. This is a dangerous practice that violates state licensure laws. CNAs' activities should be limited to taking vital signs, prepping patient charts, and other support functions.
A further concern involves "medical" security officers. We reviewed several incidents in which security staff were used to evaluate prisoner injuries, and cleared the prisoners without any medical input or consultation. Any clinical support by corrections officers must be limited, must be overseen by ihe medical department, and must be guided by clear protocols. Corrections officials may, and in fact, should, respond to medical emergencies in acute, life-threatening situations and be properly trained to do so. They should never, however, evaluate prisoners for medical reasons, perform sick call, or provide any type of non-emergency care. There are uo protocols in place at Piedmont to guide corrections officers in the very limited medical tasks ihey may perform, and ihe current level of medical department oversight of officers is insufficient.
CNAs and nurses are forced to practice beyond iheir licenses because properly credentialed staff are simply not onsite for adequate hours to provide sufficient care for ihe prisoner population. The National Commission on Conectional Health Care (NCCHC) recommends that for every 100 prisoners, there should be at least 3.5 hours of physician time each week. Based on ihat recommendation and ihe census at ihe time of our visit to ihe Facility, there should be roughly 23 hours ofphysician time each week at Piedmont. The physician, however, is only onsite for 15 hours each week. As a result, he is not able to see all ihe prisoners ihat require physician care. While ihe physician asserted ihat he is available on an "on call" basis 24 hours per day, 365 days per year, the bulk of our review did not support this assertion.
When unlicensed staffmembers are permitted to play a key role in the delivery ofhealth care, ihe probability for harm is greatly increased. Medical staffmembers are not

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interchangeable. Registered Nurses (RNs), for instance, can perform functions that LPNs cannot, and LPNs can perform functions that CNAs cannot. While highly trained and supervised nurses are the foundation ofmost effective correctional medical programs, a physician provides the medical program with clinical leadership and direction. A nurse cannot independently make a medical diagnosis. It is critical tl1at nurses, or any other staff members, are not placed in positions in which they find themselves delive1ing health care that is beyond their scope of training. This concern arises in numerous areas at Piedmont, including, for example, practices related to prisoners expeliencing alcohol withdrawal, who should be closely monitored by a physician to e11sure their safety. Although Piedmont does have an alcohol withdrawal protocol, nmses implementing the protocol are not supervised by the physician.
These concerns should be addressed as soon as possible. Current practice, in which health support personnel are functioning well beyond their qualifications, compromises access to care for prisoners and puts prisoners at risk of injury or eve11 death. Current practices also put staff members at risk oflosing their lice11ses, and both staff and the Jail at risk of!egalliability. Whe1·e medical staff members "are continually called upon to perform services for which they have not bee11 trained and for whicll they are not qualified," a cotTectional facility effectively denies prisoners access to medical care. Newman v. Alabama, 349 F. Supp. 278, 283 (M.D. Ala 1972), ajj'd in part, 503 F.2d 1320 (5th Cir. 1974), vacated in part on other grounds, 522 F.2d 71 (5th Cir. 1975) (en bane); see also Ramos v. Lamm, 639 F.2d 559, 575-76, 578 (lOth Cir. 1980) (affuming district court's finding that use of non-physician medical persollilel to make decisions and perform services for which they were neither trained nor qualified demonstrated deliberate indifference to serious medical needs and constituted effective denial of access to adequate medical care); Garner v. Winn Carr. Ctr., No. 1:08-CV-01977, 2011 WL 2011502, at *5 (W.D. La. May 18, 2011) (providing LPN to evaluate and "diagnose" prisoners ''is a failure to provide appropriate medical care to the inmates for which responsible prison officials may be liable"); Gibson v. County ofWashoe, Nev., 290 F.3d 1175, 1187 (9th Cir. 2002) ("In order to comply with their duty not to e11gagein acts evide11cing deliberate indifference to imnates' medical and psychiatric needs, jails must provide medical staff who are 'competent to deal with prisoners' problems."'), citing Hoptowit v. Ray, 682 F.2d 1237, 1253 (9th Cir.1982).
Piedmont should adjust staffing to increase the number of higher-trained staff, such as LPNs and RNs, as well as the number ofhoms that nurses and the doctor are onsite. Specifically, the Facility should hire at least two RNs, and add 6 LPNs, thus reducing the need for CNAs. In addition, the physician should be onsite no fewer than 23 hours per week. Further, cotTections officers should never evaluate ptisoners for medical needs, except as necessary to provide emergency care. Finally, Piedmont should revise its policies and procedures to establish clearly the expectations for all medical staff.
2. Piedmont's medicalpolicies lack specificity and thoroughness.
While Piedmont does have a medical manual, many of the policies are lacking in detail or specificity. There are no policies on chronic care, infection control, or quality assurance. The policies related to mental health care, and specifically those regarding potentially suicidal prisoners, do not provide the guidance necessary to preve11t harm. Fmthermore, Piedmont's policy to address the health concerns of pregnant wome11 is limited in scope. In addition, the

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policy and protocol related to alcohol withdrawal are deficient. Problems related to medical policies and procedures at Piedmont are underscored by the recent, troubling testimony of Piedmont's physician, under oath, in which he confirmed that he has not reviewed medical policies and procedures for several years, despite the fact that he has signed forms stating that he did review them.
The Facility should review the 2008 NCCHC Jail Standards and use those standards as an outline to create and adopt policies specific to the Facility, focusing from the outset on the standards deemed "essential" by the NCCHC and supplementing those as necessary to meet the medical needs of prisoners at Piedmont. Piedmont should also consider implementing an assessment tool, such as the Clinical Institute Withdrawal Assessment tool, which would set up parameters for nurses who need to monitor prisoners placed under observation.
3_ Intake screening procedures do notpromptly identifY medica{problems.
Jails must provide a prompt medical screening upon intake, and refer prisoners with medical needs to doctors and nurses for further evaluation and treatment. See Dawson v. Kendrick, 527 F. Supp. 1252, 1307 (S.D. W.Va. 1981) ("It is generally recognized that prompt medical screening is a medical necessity in pre-trial detention facilities."). Failure to properly screen prisoners for communicable diseases may constitute deliberate indifference in violation of the Eighth Amendment. SeePorteev. Tollison, 753 F. Supp. 184, 186 (D. S.C.l990), citing with approval Smith v. Sullivan, 553 F.2d 373 (5th Cir. 1977); Madrid v. Gomez, 889 F. Supp. 1146, 1257 (N.D. Cal. 1995) ("The facility should screen newly arrived inmates to identify potential medical problems and conm1unicablediseases."), citing Lightfootv. Walker, 486 F. Supp. 504, 524 (S.D. TIL 1980) ("Health care admission screening procedures, including a physical examination performed by a physician, are an essential element of a constitutionally adequate system.").
The intake screening is the jail's first opportunity to identify the needs of new prisoners and consider treatment options. Without a proper screening mechanism, prisoners may be improperly denied necessary care or medication. Absent screening, prisoners may also enter the jail with communicable diseases that can, if undiagnosed upon arrival, spread to ihe rest of the population.
Although Piedmont conducts some initial screening, the screening provided is inadequate, those conducting the screening are often not properly trained, and the results of the screening are documented inadequately, if at all. Some prisoners at the Facility are initially screened only by corrections officers, who are not trained in identifying medical or mental health needs and are not provided guidance regarding referrals to physicians. While corrections officers may perform an initial screening in rare, limited circumstances-such as during one or two quiet overnight shifts each week where medical personnel are not present-those officers must be adequately trained, and the screening must be followed by a full screening conducted by a member of the medical staffwithin hours.
Proper docUlllentatiou, including any referrals for further evaluation, is vital for determining future treatment plans and ensuring that prisoners can be monitored. We reviewed

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numerous medical records that did not contain any documentation reflecting the results of the initial screening. While we did observe some screenings, and received assurances that screenings are regularly conducted, it was impossible for us to verify that the Jail does indeed conduct a screening of each new prisoner.
We also found problems with subsequent screening for access to medical care. Like corrections officers, nurses, too, require guidance regarding which situations necessitate referrals to the physician, but Piedmont has not promulgated policies that would provide such guidance. Indeed, this deficiency was confirmed by the physician in March 2012, when he conceded that Piedmont currently has no medical manual of protocols available for the medical staff to consult. Finally, as noted earlier, Piedmont permits CNAs to perform medical screening, which they should not be doing.
In order to correct these deficiencies, Piedmont should develop and implement an intake screening system that instmcts screeners regarding which prisoners should be referred to physicians and when; ensures documentation of all infom1ation obtained through the screening process; and ensures that individuals conducting screenings and controlling access to medical care are appropriately trained and qualified.
4. Piedmont's lack ofa chronic care program places prisoners at risk ofharm.
Piedmont's lack of a chronic care program places prisoners at an unreasonable risk of harm. A chronic care program is cmcial to ensure that prisoners with known medical and mental health illnesses are identified and seen for an initial comprehensive evaluation, and then tracked to ensure periodic follow-up. A correctional institution's failure to implement policies and procedures that ensure that prisoners with chronic illnesses are identified and appropriately treated exposes prisoners to serious risks of future hann. See Shepherd v. Dallas County, 591 F.3d 445, 453-54 (5th Cir. 2009) (finding that jail's lack of chronic care exposed detainee to risk of serious injury and death); Sdnto v. Preston, 170 Fed. App'x. 834 (4th Cir. 2006) (failure to provide adequate treatment for chronic diabetes constitutes deliberate indifference). The NCCHC categorizes a chronic care program as an essential element of correctional medical care, and has developed guidelines for disease control for diabetes, hypertension, HIV, pulmonruy diseases, and seizures.
Chronic care programs prevent avoidable injuries and deaths by keeping chronically ill individuals medically stable through mechanisms such as routine, scheduled clinic visits. At present, Piedmont has no defined systems in place to track or manage prisoners with chronic conditions. By the Facility physician's own admission, medical care at Piedmont is episodic or complaint-driven, rather than proactive. For example, a prisoner who suffers from migraines and had been at the Facility for over six months at the time of our visit, had to be sent to the hospital after experiencing numbness in his body, but after returning to the Facility, had never been checked by the physician. This case reveals weaknesses in both physician coverage and chronic care follow-up. Piedmont's lack of preventative/chronic care can result in harm or risk ofhann to prisoners. The following examples are illustrative:

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• Prisoner A2 entered the Jail with a history of seizures. He was placed on Dilantin, a drug that can cause both neurological and cardiac side effects, but, despite the fact that he had been at the Jail for over eight months at the time of our inspection, was never evaluated for proper medication dosage or toxicity leveL
o Prisoner B reported a history of chronic obstructive lung disease and hypertension upon entering the Jail on March 18,2010. He was placed on Theophylline, a toxic medication that should be used with caution, yet at the time of our review, he had never had a drug level to assess the toxicity and therapeutic levels of the medication, and had never been evaluated for complications associated with hypertension or cardiac risks, as would be expected. In fact, he had not had a visit with the physician to address his chronic conditions at alL Prisoner B was evaluated by a CNA on May 21, 2010 for chest pain, and was eventoally sent to the hospital for his pain, yet he never had a follow-up visit with the physician for his chest pain.
• Prisoner C, at Piedmont since March 30, 2010, was placed on Coumadin, a potent blood thinning medication, for heart disease, and Simvastatin for high cholesteroL Both of these medications can be toxic and need to be monitored for therapeutic effect At the time of our review, no drug tests had been conducted and the physician had not scheduled any chronic care visits with Prisoner C.
• Prisoner D entered the Jail with a histmy of hypothyroidism, mental illness, and hypertension. He was given medications to address these conditions, but no blood work was ever done to determine ifhis thyroid condition was responding to the medication or if he received the proper dosage. Piedmont medical staff also failed to monitor the dmg used to adjust Pl~soner D's cholesterol level, which placed him at great 1~sk for undetected liver toxicity.
As the above examples illustrate, Piedmont's lack of a chronic care program exposes p1~soners to a substantial risk of significant harm. To remedy this, Piedmont should establish a chronic care program that defines what illnesses qualify for inclusion in the program (for example: diabetes, hypertension, dyslipidemia, lllV, cardiovascular diseases, seizure, pulmonary illness, and mental illness); ensures that prisoners with chronic care issues are identified and examined by the physician; tracks prisoners in the program and schedules periodic assessments; provides for diagnostic tests at an initial comprehensive visit; makes lab work available at appoinlolents in order to dete1mine the status of disease control; and outlines a clinical plan for each chronically ill prisoner.
5. The lack ofcomprehensive health assessments places prisoners at risk.
Comprehensive health assessments, conducted within fomteen days of arrival, are an integral part of a correctional medical system, because they may identify medical problems that were not discovered during the initial screening process. See, e.g. Roberts v. Mahoning County,
2 Prisoners are refe1Ted to by letter to protect their privacy.

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495 F. Supp. 2d 719, 769 (E. D. Ohio 2007) (consent judgment requiring that new medical providers contracted by jail conduct comprehensive health assessments within fourteen days of prisoners' arrival at the jail).
Thorough health assessments, conducted after the prisoner has adjusted to the jail setting, are an essential tool for jail clinicians. Such assessments, in addition to identifying problems that were not raised or addressed in the initial screening, allow medical staff to develop more complete treatment plans for prisoners with known medical problems, including, for example, diabetes, asthma, and depression. Without a detailed evaluation of each prisoner, chronic or less immediately apparent problems can go undiagnosed or mistreated. The evaluation further allows medical staffto develop a medical baseline for each prisoner. Moreover, health assessments can assist in identifying and treating the spread ofcommunicable diseases that can impact prisoners, staff, and the wider community. Deficiencies related to health assessments have been a subject of concern for other experts and inspecting bodies reviewing Piedmont's medical services in the past.
Piedmont should develop and implement a system to provide a comprehensive health assessment within fourteen days ofthe anival of each prisoner. A physician, physician assistant, or nurse practitioner should conduct the health assessments. However, RNs could perform health assessments, provided that a physician provides documented supervision and training.
6. Piedmont's sick call system places prisoners at risk ofharm.
Sick call systems are essential to the provision of adequate cmrectional medical care. Todaro v. Ward, 431 F. Supp. 1129, 1146 (S.D.N.Y. 1977) ("Courts have held that a sick call procedure for prompt referrals of those in need to a physician is constitutionally required."), a.f!d sub nom. Todaro v. Coughlin, 652 F.2d 54 (2d Cir. 1981), and a.f!d, 565 F.2d 48 (2d Cir. 1977) (citations omitted). The sick call system mnst be run by medical personnel who are appropriately trained in meeting the medical needs ofthe prisoner population. Madrid, 889 F. Supp. at 1258 ("While medical teclmical assistants or their equivalent may permissibly be the first to examine inmates with physical ailments, they must be properly trained to perform this function and adequately supervised.").
Prisoners rely on a jail's sick call system as an entry point to medical care within the facility, and jails rely on a sick call system to ensure that medical problems are addressed as early as possible to prevent unnecessmy suffering, avoidable injury or death, and the increased medical costs associated with ilh1esses that have been allowed to linger and worsen.
Currently, Piedmont's sick call system places prisoners at a11 unreasonable risk ofhmm, because under-qualified LPNs and CNAs manage the sick call system without the supervision of a physicim1. CNAs are not sufficiently credentialed to perfmm sick call or evaluate prisoners. The LPNs at Piedmont, although credentialed, currently lack the training necessary to develop long-term treatment plans. Furthermore, Piedmont lacks standardized forms for nurses to use in their evaluations. These forms, if properly developed, would guide nurses and establish protocols for referrals to the physician. Indeed, this deficiency was confirmed by the physician when he testified in March 2012 that Piedmont currently has no medical manual of protocols

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available for the medical staff to consult. Problems with Piedmont's sick call system are longstanding, and have been noted by other experts and inspectors in the past.
While changes to the current sick call system are required, we do note with approval that prisoners seem to be able to access the medical staff when necessary. Most prisoners we spoke with reported being seen by someone on the medical staff within days of submitting a sick call slip, and none reported problems accessing medical care for true emergencies. Our concern is whether prisoners' initial contact with medical staffvia the sick call system routinely results in the prisoner being referred for the appropriate level of care based on the prisoner's medical needs. Nonetheless, prisoners' ready access to sick call and emergency medical care is a positive development, and seems to represent improvement, as a lack of access to care allegedly led to several deaths and numerous other issues at the Facility in the past.
In order to address the problems related to sick call, Piedmont should establish standardized tools for use during sick call evaluations. These tools will allow nurses to properly triage prisoners' medical needs and ensure they are refened for and provided appropriate treatment in a timely mmmer. CNAs should not be allowed to perform clinical evaluations, and their role in the sick call process should be limited to prep work, such as taking vital signs. Further, the physician should provide oversight of the sick call process by pe1iodically reviewing the nurses performing sick call, in order to ensure that personnel are not practicing beyond their clinical training.
7. The lack ofany quality assurance program at Piedmont puts prisoners at risk of harm.
Quality assurance ("QA"), or quality improvement, is an important tool for any
conectional medical staff. See, e.g., Codyv. Hillard, 599 F. Supp. 1025, 1058 (D. S.D. 1984)
("Several courts have held the lack of quality control over medical care, when considered among other health care deficiencies, unconstitutional under the Eighth Amendment."), ajfd, 799 F.2d 447 (8th Cir. 1986) on rehg, 830 F.2d 912 (8th Cir. 1987).
A functioning, effective QA progrmn will identify problems in the delivery ofmedical care, and create mechanisms to rectifY those problems. One of the major components of a QA system is to share findings with staff so that they can learn from past mistakes. QA often involves the physician reviewing and analyzing nursing assessments and other critical clinical
activities, such as chronic care and sick calL It should also involve the review of all deaths at the
Facility, in order to ascertain compliance with the standard of care and educate staff about trends and causes of prisoner deaths. An effective QA process will improve the clinical care provided and reduce poor outcomes.
Piedmont currently has no QA progrmn, which means that it cannot be proactive in identifYing problem areas before a poor clinical outcome occurs. The Facility should develop a QA program to review the clinical performance of sick call, health assessments, intake, chronic care, medication administration, and emergency care. This QA progrmn should include a comprehensive and documented mortality review and response after any deaths.

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8. Training gaps increase the likelihood ofhann.
As noted above, we reviewed several incidents in which secmity staff were used to evaluate prisoner injmies, and cleared the prisoners without any medical input or consultation. Conections officials may and should respond to medical emergencies in acute, life-threatening sitnations. But they must be properly trained to do so and should not be asked to make the clinical-level evaluations they are asked to make at Piedmont A failme to train secmity and medical staff can cause serious medical harm and subject an agency to legal liability. See, e.g., Doe v. Broderick, 225 F.3d 440, 456 (4th Cir. 2000). While Piedmont does conduct training for medical and secmity staff, the training on suicide prevention and mental health is severely lacking. Training is necessary even where officers can call medical staff at any time, as officers are nearly always the first responders to a medical crisis and, with proper training, may be able to prevent more serious injury or even save a life.
Piedmont should ensme all officers are trained in providing first-responder medical care. The Facility should also develop and implement training for suicide prevention and mental health.
9. Piedmont's co-pay system can result in denial ofaccess to care.
Policies which require that a prisoner pay a co-payment for health care do not constitnte per se deliberate indifference to a serious medical need in violation of the Eighth Amendment. However, such co-payment policies can rise to the level of a constitutional violation where prisoners are denied access to necessruy health care due to their inability to pay. See Johnson v. Dep'tofPub. Safety & Carr. Services, 885 F. Supp. 817, 820 (D. Md. 1995); Gonzales-Reyna v. Ellis, No. 1:09-cv-522-AJT/TCB, 2009 WL 2421482, at *3 (E.D. Va July 27, 2009); Collins v. Romer, 962 F.2d 1508, 1513 (lOth Cir. 1992). Therefore, while jails may charge small co-pays for medical care, co-payment policies must be flexible to enable indigent and chronically ill prisoners to access health care without in1posing 111111ecessary hardship. See Johnson, 885 F. Supp. 817, 820. Where these exceptions are not in place, even relatively small co-pays can create barriers to access to necessary health care.
At Piedmont, prisoners are required to pay considerable fees for most clinical services. Piedmont prisoners pay $12.50 to see anmse and $20.00 to see the doctor, while emergency visits cost $50.00. Prisoners are charged $10.00 per month for medication. The amounts Piedmont charges far exceed the generally accepted co-payment runounts across the country. Most state conectional systems charge co-pays in the two to five dollar range, and rarely are they more than $10. See, e.g., http://www.michigan.gov/documents/conections/03_04_101_268638_7.pdf($5 co-pay in Michigan prisons); http://www.drc.ohio.gov/web/medical.htrn ($3 co-pay in Ohio prisons); http://ww-w.portal.state.paus/portal/server.pt/document/919468/820_copayment_[or_medical_services__pdf ($5 co-pay in PeJ.lllsylvania prisons). In fact, the Virginia Department of Conections charges a five dollru· co-pay for most medical services. Virginia Dept. of Conections, Operating Procedure 720.4: Co-Payment for Health Care Services, (runended Nov. 15, 2011), www.vadoc.state.vaus/about/procedmes/documents/700/720-4.pdf. Moreover, the co-pays charged by Piedmont are well in excess of most fees which have

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previously been found constitutional. See Johnson, 885 F. Supp. at 818 (co-pay of two dollars constitutional); Collins, 962 F.2d at 1517 (three dollar co-pay constitutional); Go11Zales-Reyna, 2009 "WL 2421482, at *3 (five dollar co-pay constitutional).
While the Piedmont inmate/detainee handbook and medical protocols make clear that prisoners cannot be denied access to medically necessary services based upon their inability to pay, there can be no doubt that, in actuality, inability to pay impacts whether prisoners request medical care. Numerous prisoners we spoke "ith said that the co-pay fees adversely affected their decisions whether to seek needed medical care, especially when paying for a medical appointment would mean foregoing hygienic or other items that the prisoner could otherwise purchase with the money he or she would have tu use as a co-pay. Universally, the prisoners we spoke with who had been incarcerated at multiple facilities told us that Piedmont has the highest co-pays of any facility they had encountered.
The NCCHC has recognized numerous problems, like that illustrated above, created by medical co-pays, all of which are only exacerbated when the co-pays are exceedingly high, as they are here. For exan1ple, co-pays place prisoners in tl1e position of having to choose between paying for other much needed items, such as hygienic products, or receiving medical attention. Nat'l Comm'n on Corr. Health Care, Position Statement: Charging Inmates a Feefor Health Care Services (Oct. 2005), http://www.ncchc.org/resources/ statements/healthfees.htu1L Further, when prisoners avoid medical care for what may initially be minor situations, those situations may deteriorate, leading to serious consequences for the inmate or the infection of others. !d. Accordingly, the NCCHC has recommended a number of guidelines, including the following:
• Only services initiated by the inmate should be subject to a fee or other charges. No charges should be made for the following: admission health screening (medical, dental, and mental) or any required follow-up to the screening; the health assessments required by facility policy; emergency care and trauma care; hospitalization; infirmary care; prenatal care; in-house lab and diagnostic services; pharmacy medications to maintain health; diagnosis and treatment of contagious disease; chronic care or other staff-initiated care, including follow-up and referral visits; and mental health care including drug abuse and addiction.
• The assessment of a cllarge should be made after the fact The health care provider should be removed from the operation of collecting the fee.
• Charges should be small and not compounded when a patient is seen by more ilian one provider for the same circumstance.
• No inmate should be denied care because of a record of non-payment or current inability to pay for same.
• The system should allow for a minimum balance in the inmate's account, or provide another mechanism permitting the inmate to have access to necessary hygiene items (shampoo, shaving accessories, etc.) and over-tl1e-counter medications. !d.
It remains an open question whether a $50 co-pay for emergency visits is per se unconstitotional. But even lower co-pays may be unconstitutional if they are shown to effectively deter legitimately needed medical treatment At Piedmont, ilie exceedingly high co-

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pay fees, in combination with information indicating that they may be serving as a barrier to prisoners receiving necessary medical care, may well run afoul ofconstitutional requirements.
Accordingly, Piedmont should immediately revise the co-pay policy to exclude all health care required by the Facility, including health assessments and mental health care. In addition, Piedmont should establish exceptions to the co-pay requirement for necessary medical care, including chronic care and emergency visits, so that prisoners are not dissuaded from seeking and receiving care that is essential to their health. Furthermore, the Jail should require only a single, lower co-pay fee to see a nurse, with no further fee to see the doctor if the prisoner is refened for further evaluation. In addition, Piedmont should establish a minimum balance in the prisoner's account, in order to ensure that a prisoner who is charged a co-payment will retain the ability to purchase hygiene items and over-the-counter medications.
B. Mental Health Care at Piedmont is Sub-Standard and Places Prisoners at Risk of Harm
Jails are constitutionally required to treat prisoners with mental health needs. Estelle, 429 U.S. at 104. Failure to properly treat and monitor individuals with suicidal thoughts or behaviors is a violation of the Eighth Amendment. Buffington v. Baltimore County, Md, 913 F.2d 113, 120 (4th Cir. 1990) ("where police know that a pretrial detainee is on the verge of suicide, that psychological condition can constitute the kind ofserious medical need to which state officials must, under the due process clause, not be deliberately indifferent"). Officials are also required to provide appropriate psychiatric services, including evaluation, treatment, and supervision, to protect prisoners from harming themselves or others. De'Lonta v. Angelone, 330 F.3d 630 (4th Cir. 2003) (protection against self-mutilation is serious medical need to which prison officials may not be deliberately indifferent); Dawson, 527 F. Supp. at 1308 ("... failure to provide timely access to ... psychiatric or psychological personnel" contributes to deliberate indifference).
Without proper evaluation and treatment, prisoners with scrious mental illness may needlessly suffer and cause significant security challenges, becoming actively psychotic, aggressive, violent, or difficult to control.
While many mental illnesses are treatable with the right medications and therapy, a disjointed mental health system places prisoners at risk of injury and illness fi-om improper medication or dosage levels, suffering the ongoing impact ofuntreated serious mental illness, and self-harm.
Piedmont's mental health care system is deficient in a number of ways:
Inadequate Psychiatric Staff: The Jail has no psychiatrist available to prescribe psychotropic medications or evaluate their effects. This is a gross violation of standard medical practice. Instead, a clinical counselor, who is not a trained or licensed physician, serves as the sole mental health staff member, and is only present at the Jail for one day per weelc. She meets with patients only upon their request or upon a report of suicidal ideation or a suicidal act. Prisoners who are given psychotropic medication are not monitored for side effects or proper

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dosages. The American Psychiatric Association recommends that there be one full-time psychiatrist for every 75-150 patients with serious mental illness on psychotropic medication in prison. At the time of our visit, there were 75 prisoners on mental health medications in the Facility, indicating the need for at least 20-40 hours of onsite psychiatric care. The Jail, in contrast, provides none.
Inadequate Assessmenls and Follow-up: Additionally, no routine mental health evaluations are performed, even for prisoners with a history of mental illness or those on psychotropic medications, and there are no documented assessments or treatment plans for prisoners with mental illness. Diagnostic blood tests, which are needed when certain medications are prescribed, are not routinely conducted or properly documented. For example, Prisoner E was prescribed Tegretol and Lithium for his mental illness. Both of these medications require periodic drug levels, due to their toxicity. Lithium, in particular, can be lethal ifnot managed correctly. Nevertheless, no drug levels were taken and Prisoner E had not, at the time of our review, had any follow-up to assess his mental status. We also reviewed the records of several other prisoners prescribed Lithium without blood work or other follow-up being performed.
Inadequate Suicide Prevention: Prisoners at Piedmont who exhibit suicidal behavior or express suicidal thoughts are dealt with inappropriately. Prisoner F, who reported a history of suicidal ideation, was prescribed Haldol, but never received a comprehensive mental evaluation or any follow-up on the effects of the medication. Other suicide precautions are also lacking, such as staggered 15-minute checks of prisoners on suicide watch, and the availability of cutdown tools for officers. Significantly, because prisoners can only be released from suicide watch after being seen by the counselor, who works only one day a week, prisoners can be-and have been-on suicide watch for up to a full week unnecessmily. Maintaining prisoners on suicide watch unnecessarily is punitive and can discourage those who truly need help from seeking it. The physician should be actively involved in evaluating prisoners on suicide watch, but cunently is not. For example, Prisoner G was placed on observation for almost a week with no physician evaluation, and there were no notes or documentation in her file regarding her treatment or progress.
To remedy these problems, Piedmont should ensure that prisoners with mental health needs are properly evaluated, treated, and mouitored by a licensed psychiatrist who is onsite at least 20 hours per week. That psychiatrist should be supported by the clinical counselor, who could work in conjunction with a nurse practitioner to provide a sufficient number ofhours of coverage each week. All prisoners with a known mental illness should be referred to the psychiatrist within fourteen days of arrival, assuruing an initial screening is completed, and individuals with more acute needs-such as those who are suicidal or grossly psychotic-should be seen and treated as soon as the Facility becomes aware of their condition. Prisoners who are prescribed psychotropic medication should also be evaluated by the psychiatrist within two weeks of starting a new medication. Piedmont should develop and implement policies to ensure monitoring of individuals with chronic mental health illness, and completion ofblood work aud other follow-up as necessary. Finally, all plisoners on suicide watch should be actively monitored to ensure that no prisoner is restricted longer than necessary.

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C. RLUIPA
We note, as a general matter, that we were pleased to see a number of recent changes that Piedmont has made to ensure that it is in compliance with RLUIPA. These changes should be maintained, as they are both necessruy under the law and beneficial to the Facility and society at large. Prisoners who are petmitted to practice their religion are less likely to engage in misbehavior or otherwise cause dismptions to the jail environment, and religious worship supports rehabilitation. See 146 CONG. REC. 86678-02, at S6689 (daily ed. July 13, 2000).
RLUIPA provides that no institution owned or operated by, or on behalf of, any State or local government, including correctional facilities, "shall impose a substantial burden on the religious exercise of a [resident]." 42 U.S.C. § 2000cc-l(a). This prohibition includes a substantial burden on religious exercise resulting from a mle of general applicability. Id "Religious exercise" is defmed to include "any exercise of religion, whether or not compelled by, or central to, a system of religious belief" 42 U.S.C. § 2000cc-5(7)(A). In order to overcome this prohibition on burdening religious exercise, a govermnent must demonstrate that imposition of the burden is: (1) "in furtherance of a compelling govemmental interest"; a11d (2) "the least restrictive means of furthering that compelling govennnental interest." 42 U.S .C. § 2000cc-1 (a). The Fourth Circuit, in interpreting RLUIPA, has held that a substa11tial burden occurs when an act or omission "put[s] substa11tial pressure on an adherent to modifY his behavior and to violate his beliefs." Lovelacev. Lee, 472 F.3d 174, 187 (4th Cir. 2006) (quoting Thomas v. Review Bd ofIndiana Employment Sec. Div., 450 U.S. 707, 718 (1981)).
Below, we briefly address our observations about several discreet issues within the RLUIPA context Because allegations we had previously received focused mainly on the denial of religious rights to Muslint prisoners, our comments center largely on that population.
1. Religious Meals
Piedmont serves a pork-free diet, which allows it to meet the needs ofmany of those prisoners who may adhere to a religious diet. Piedmont also provides special meal service to those observing Ramadan.
While the food service at Piedmont for religious observers thus seems to be adequate at present, the Jail should be aware that simply providing a pork-free diet may not be sufficient to accommodate all prisoners' religious exercise. Piedmont should ensure that prisoners can at least purchase from the commissruy religiously acceptable foods to augment the diet provided.
2. Religious Services
Piedmont currently permits Muslim prisoners to participate in a Ju'malt service each Friday. This practice began shortly after weissned our Notice Letter inforrning the Facility that we were opening our investigation. Piedmont should continue to allow Jn'malt services to ensure it is not in violation ofRLUIPA. We observed the Ju'malt service, in which the Jail's chaplain participated, a11d we appreciate his commitment to allowing prisoners of all faiths to practice their religions while incarcerated.

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3. Religious Possessions
After our investigation began, Piedmont started permitting Muslim p1isoners to possess Korans. Prayer mgs, we were informed, are sold in the co=issary, and we saw several prayer mgs being used during the Ju'mah service. Piedmont has fulfilled its legal obligation by pe1mitting prisoners to practice their religion with the appropriate possessions. Piedmont should continue this practice to maintain compliance with federal law.
4. Religious Headwear
During our investigative tour, several Muslim prisoners informed us that, while they were allowed to wear religious headgear (the kufi) in their housing units, they were not permitted to wear them outside of those units. A Piedmont official confumed to us that this accurately represented policy.
After we raised this issue, Piedmont changed the policy so that religious headgear can now be worn throughout the Facility, but when a prisoner wearing such headgear enters or leaves a housing area or any Jail program, the headgear will be searched for contraband. Jail directives also now provide that prisoners shall have access to religious headwear. These policy changes should also remain in place, as they are necessruy to ensure that the Facility is in compliance with its obligations under federal law.
IV. Summary of Remedial Measures
To remedy the deficiencies identified above, Piedmont should promptly implement the minimum remedial measures set forth below. Specifically, the Facility should:
• Review the 2008 NCCHC Jail Standards and use those standards to create and adopt facility-specific policies, focusing from the outset on the standards deemed "essential" by the NCCHC.
• Revise medical policies to include policies on chronic care, infection control, and quality assurance.
• Increase medical staffing by hiring additional staff with higher credentials (e.g. RNs, LPNs, and a psychiatrist) and increasing the hours that current staff-most especially the doctor-are onsite. Specifically, hire at least two RNs; add 6 LPNs, which will allow for a reduction in the number of CNAs; increase the physician's onsite hours to at least 23 hours per week, and, in conjunction with hiring a psychiatrist, increase the mental healtl1 counselor's hours or hire a nurse practitioner to cover additional hours.
• Limit the tasks that CNAs undertake to those that they are credentialed to perform, and ensure that proper physician supervision is provided. Specifically, an1ong other things, CNAs should not be performing intake screenings or clinical evaluations, and should not take medication orders.

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• Ensure that security officers are not rendering medical decisions regarding prisoners' care, and make sure that there are clear gnidelines in place for any security officers providing clinical support, with physician oversight.
• Ensure that all initial screenings are performed by trained staff and documented electronically, including documentation of any referrals to the physician.
• Implement a policy that provides guidance to nurses about when to refer prisoners to the physician following screening, sick call, or emergency visits.
• Conduct comprehensive health assessments of all prisoners within fourteen days oftheir arrival, with a physician either conducting the screening or overseeing RNs who conduct the screening.
• Provide for physician oversight, including periodic review, of sick call, with nursing protocols and clinical assessment forms that guide the nurses performing sick call.
• Develop a detox procedure that includes the Clinical Institute Withdrawal Assessment tool for prisoners at risk of alcohol withdrawal and requires physician input before nurses can treat prisoners 'vithdrawing from abused substances.
• Implement a chronic care program that identifies prisoners for eurolhnent; defines illnesses to be inclnded; ensures that enrolled prisoners are tracked and scheduled for periodic assessments; requires diagnostic tests; and ensures that all prisoners with known medical or mental health issues are scheduled for routine visits with the physician or a psychiatrist as appropriate for their condition.
• Review and revise the co-pay policy to ensure that it does not prevent prisoners from accessing health care. The review should assess the co-pay amount to detem1ine whether it is a deterrent to seeking care and make provisions for indigent prisoners and prisoners with chronic illness.
• Provide routine evaluations to prisoners with a history ofmental illness and those on psychotropic medication, with documented treatment plans, within 14 days of arrival.
• Provide inlmediate treatment to prisoners who are suicidal or psychotic, as soon as those conditions are known to the Facility.
• Ensure that the physician provides follow-up visits to prisoners on psychotropic medications, including diagnostic blood tests for plisoners on certain mental health drugs, based on the toxicity profile of the medication.

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• Ensure that the physician sees prisoners on snicide watch when the mental health staff is not present, and ensure that prisoners are not kept on watch longer than necessary.
• Ensure that 15-minute watches for prisoners on snicide watch are staggered, and ensure that all officers have cut-down tools.
• Institute a quality assurance program that, among other things, reviews the
clinical performance of sick call the health assessment process, the intake
process, the chronic care program, medication administration, and emergency care, and includes mortality reviews after any deaths.
• Implement training on first-responder medical care, mental health and suicide prevention for security staff.
• Continue to serve meals that allow prisoners to adhere to a religious diet, including special meal service for religious holidays, and establish a plan to meet the needs ofprisoners who may reqnire more than a pork-free diet in order to meet the dictates of their religion.
• Continue to permit prisoners to participate in religious services, possess religious books and other materials (such as prayer rugs), and wear religious headgear throughout the Facility.
********
We hope to continue working with Piedmont in an amicable and cooperative fashion to resolve the above-outlined concems regarding conditions at the Facility. We know that, since our onsite visit, Piedmont has committed to taking various steps to address many of the issues we raised at our exit presentation. We appreciate the Jail's proactive efforts, which give reason to believe that the Jail will be able to resolve all the matters about which we have expressed concem.
We look forward to learning of the progress Piedmont has made thus far, and to discussing the above findings with the Jail. As always, we remain available to discuss any questions or concerns that yon might have regarding our investigation.
Please note that this letter is a public document. It will be posted on the Civil Rights Division's website.

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Should you have any questions or concerns regarding this letter, please feel free to contact Jonathan M. Smith, Chiefof the Civil rughts Division's Special Litigation Section, at (202) 514-5393.
Sincerely,
Thomas E. Perez Assistant Attorney General
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cc: Neil H. MacBride, United States Attorney United States Attorney's Office Eastern District of Virginia
Mr. Ernest L. Toney Superintendent, Piedmont Regional Jail 801 Industrial Road Farmville, VA 23901
Robert A. Dybing, Esq. ThompsonMcMullan, P.C. 100 Shockoe Slip Richmond, VA 23219

 
 Piedmont Regional Jail Authority First Monitor Report
October 9, 2014
James Welch, RN

Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
October 9, 2014
The report is based on the Qualitative and Quantitative measures as required by the settlement agreement with the Piedmont Regional Jail (PRJ). Each measure will be evaluated against the reports as presented to the Monitor and site visits conducted. Reports such as the monthly report from PRJ have been used to provide this document. As this is the first report, it will be important for each of the parties to address if this is the format by which all other reports will follow. There are also specific indicators identified in the settlement agreement. In future documents as PRJ moves toward compliance with the indicators, this report will highlight where they have moved toward substantial compliance. The indicator spreadsheet is an attachment to this initial report. It is premature to provide a grading for this initial report as many of the processes and policies have just recently been developed and implemented.
Site visits were conducted on December 16 – 18, 2013, January 6-8, 2014 and July 28-30, 2014. Monthly reports from PRJ beginning in April 2014 were reviewed and data verified during site visits. Site medical staff and correctional staff were interviewed to assess the validity of the data and observations. The staff at the PRJ have been cooperative and helpful for the work of this Monitor. No areas of the facility have been off limits, nor have there been any restrictions placed on the movement of the Monitor to visit any areas within the facility.
Don Hunter, Superintendent of the Piedmont Regional Jail and his staff are fully engaged and willing to work with the Monitor to improve conditions at the Jail. During the first Monitor visit the Monitor met with Jim Garnett the Chair of the Board of Directors for the PRJ. Discussion with Mr. Garnett revolved around the settlement agreement and the work that would be needed to bring the facility up to compliance with constitutional requirements.
Jim Davis, the PRJ compliance director has been most helpful in providing information and documents needed for the continuing review of the PRJ.
During the first visit it was obvious that the entire staff were committed towards making the system better, but the challenges were significant. They have worked over the past few months to improve conditions and policies at the jail. While there is not a specific item in the settlement agreement about the physical space provided, the PRJ has made significant improvements to the medical areas. The physical
2

Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
space is better laid out and the increase in the examination areas, ability of the physician and dentist to examine patients has been much improved due to the increased space.
PRJ has made efforts towards achieving compliance with the settlement agreement and are to be commended for their initial efforts. While changing a system takes time, they have shown that they are committed and willing to make the changes necessary to meet the medical and mental health needs of their offenders.

Qualitative and Quantitative Outcome Measures

MEDICAL CARE

•

The facility will provide 3.5 hours of physician time per week for every 100

prisoner.

The census at the PRJ has been between 545 and 599 during the current Monitoring period. The current Physician staffing is Monday 7:30AM – 3:30PM, Wednesday 7:30AM – 1:30 PM and Thursday 7:30AM – 3:30PM. This gives the PRJ 22 hours of physician time per week. This meets the requirement as set forth in the settlement agreement. It was noted that Dr. Rula, the physician on staff, has been the constant in the Medical area since the Monitoring period began. Other physicians have been providing services at the facility, but Dr. Rula has been the constant. One observation that has been made is that when Dr. Rula is on vacation, the substitute physician causes a delay in services for the offenders. Data from the monthly site report, and review by the Monitor showed a delay in referrals to the physician of up to 12 days. This is exacerbated when there is a substitute physician. I recommend a review of the reasons for the delays and triage of the referrals to the physician. A strategy should be developed for assuring that those offenders with particular medical issues are seen in a timely fashion. Assure that substitute physicians are familiar with, and able to provide care for offenders, that does not cause a delay in service delivery.

•

For a Count Below 600: There will be a Minimum of (1) RN and (6) LPNs (count

below 600) / For a Count Above 600: There will be an Additional (2) LPNs.

There has been much turnover in medical staff during this initial phase of the Monitoring. As of the July visit there were 5 LPN’s and 2 RN’s. One of the RN’s is a Health Services Administrator/Director of Nurses (HSA/DON). During the visit MEDIKO (the current provider of healthcare services) indicated hiring additional LPN staff. The current staffing pattern meets the intent of the agreement with the additional

3

Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

RN on staff. A new DON/HSA, Mary Trammell-Jones was on site. The former Regional HSA, Janet Dobson is no longer employed with MEDIKO. This change has caused some challenges with consistency of medical procedures. These will be noted in sections of the report.

•

If Health Assessments are not being completed within 14 days the facility will hire

an additional (1) RN.

Data from the latest report showed that there were 14 health assessments out of 233 that were not completed in the 14-day time frame. MEDIKO has hired an additional RN. They were in the process of hiring additional LPN staff during the July visit. Hopefully this will correct the issue. Part of the challenges in this area were caused by the security computer system and the COR-EMR , medical record system not communicating. This caused great confusion as to who was and was not in that 14 day period. The change in nursing and medical management at the site also caused a delay in coordinating efforts in this area.

•

All persons providing care will meet applicable state licensure and/or

certification requirements and, they will practice within the scope of their

training/licensure. Licenses will be up-to-date with no lapses.

Review of license documents shows that each of the medical and mental health staff is appropriately licensed. Orders reviewed, and policies assessed indicated staff functioning within the scope of their respective licensure.

•

Certified Nursing Assistants will only perform tasks as related to support

functions (e.g. vitals, prepping charts, etc.).

There were no CNA’s performing tasks at the facility.

•

Clear guidelines/policies are in place for any individuals providing clinical

support, with physician oversight. CO's should not provide any type of non-emergency

medical care.

Policies were approved and are in place. While Dr. Rula has been present at the site there is no specific documentation of the physician oversight as required except for the signature that the intakes and assessments have been signed off by the physician. PRJ policies do not allow for CO’s to provide any direct medical care to offenders.

POLICIES

4

Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

Policies shall be in place that establish clear direction and expectations for all

staff.

Over the first few months PRJ established policies that relate to medical and mental health care for any offender housed in the facility. The Monitor and the DOJ have reviewed and approved all policies.

•

All policies should be revised consistent with the 2008 National Commission on

Correctional Health Care Jail Standards. (38 standards for policies - see check list)

All policies except one have been consistent with the 2008 National Commission on Correctional Health Care Jail Standards. One of the policies states that intake screens (receiving screening) will be done within 72 hours. This does not seem to be consistent with the compliance indicator. “A receiving screening takes place for all inmates as soon as possible.” It is unclear if this Monitor or the DOJ overlooked the time frame when the initial policies were approved, but the 72 hour time frame is not consistent with the required NCCHC standard. It is requested that the PRJ review the time frame and come up with a period that would meet the standard. To quote the Standard – “ Receiving screening is performed in all inmates on arrival at the intake facility to ensure that emergent and urgent health needs are met.” After inquiring about the time frame with multiple jurisdictions, a time frame of 24 hours or less has been the most consistent response. This protects both the offender and the institution, assuring that any urgent medical condition is addressed. The Monitor is willing to work with PRJ to develop strategies that will assist PRJ in meeting the standard.

INTAKE

•

90% of the Medical Screening portion of Intake Screening is performed by a

Qualified Health Professional.

During this first Monitoring period, the medical staff has been working to assure that a Qualified Health Professional completes all receiving screenings. During the July Monitor visit a Qualified Health Professional had conducted all receiving screenings as noted by the signatures on the intake screening forms.

•

90% of the Initial Screenings are fully documented and available to medical staff

in each offenders on line medical file.

Intake screenings are available in the COR-EMR electronic system. Each was fully documented. The monthly data provided by PRJ showed that 174 were completed within 24 hours, 66 within 48 hours, 12 within 72 hours and 6 fell over the 72 hour framework. Challenges noted included the fact that there were no female officers available to escort female offenders to the medical area for the screening. During the July

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
site visit both the superintendent and the compliance director assured the Monitor and DOJ representative that there was a female officer who has been assigned to the medical area to assure there is no delay for female offenders. As PRJ and MEDIKO staff review the policy and procedure for intake screenings it will be critical to assure that additional staff are available to conduct screenings during intake surges that often occur near holidays and predictable circumstances such as large special events. It will also be important to provide ongoing training for those medical staff conducting receiving screenings.

•

Policies adopted will be consistent with applicable professional standards,

providing guidance when prisoners should be referred to a physician after initial intake

screening.

Policies are consistent with NCCHC standards. As is noted in subsequent sections, referrals to the physician have been delayed. That delay has been up to 12 days. No adverse events have been noted at this point, but such a delay can cause adverse outcomes or conditions that arise from the timing of treatment. There should be documentation when there is a delay in the referral process to assess why the delay occurred and what steps can be taken to avoid the delay.

CHRONIC CARE

•

The Chronic Care policy will be implemented with disease-specific clinical

guidelines.

A chronic care policy has been developed, and has recently been implemented. While the clients may be seen for chronic conditions, a systematic approach to those with chronic illnesses was recently adopted. During the first and second visits the Monitor worked with the RN staff to develop a process for delivery of a chronic care program. Between the second and third visits a significant shift in medical and mental health personnel occurred which seemed to delay the implementation of the chronic care program. In the July PRJ monthly report, chronic care clinics had been conducted for four chronic care conditions (Cardiovascular, Endocrine, Respiratory, and Immunity).

•

The guidelines will define illnesses that qualify for inclusion in the program.

The guidelines identify those conditions that are included in the chronic disease program. Those conditions are: Cardiovascular, Endocrine, Gastroenterology, Respiratory, Neurology and Immunity.

90% of prisoners with chronic care issues are identified and examined by the physician
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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
Data were not available, as the program has recently been implemented.
100% of the prisoners in the program are tracked in the COREMR system. For those offenders that were identified during the July Monitor visit, their chronic care visit was tracked in the COR-EMR program. Due to the recently implemented program percentages are not available.
90% of the prisoners in the program are scheduled for periodic assessments. Data was not available to assess if the prisoners were scheduled based on degree of control.
90% of the prisoners in the program are provided diagnostic tests at the initial comprehensive visit.
Data was not available as the program was recently initiated. Review of COR-EMR charts from the three Monitor site visits showed inconsistent laboratory diagnostic testing. Some occurred prior to the visit and others were ordered during the visit with the physician. This is an area where consistency is crucial to the outcome for the offenders.
90% of the lab work will be available at appointments to determine the level of disease control.
Data were not available as the program was recently initiated. Review of COR-EMR charts from the three Monitor visits showed inconsistent laboratory diagnostic testing. Laboratory testing is ordered, but not always prior to the visit with the physician. With the implementation of the program this should become consistent.
90% of chronic care patient’s will have a comprehensive clinical plan. Data for the entire program offender compliment is not available, but for
those medical charts reviewed, a comprehensive clinical plan was in place.
HEALTH ASSESSMENTS
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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

Develop and implement a system to provide each prisoner with a comprehensive

health assessment.

PRJ has developed and implemented a system to provide a comprehensive health assessment for those offenders who are in their custody for the 14 day period. The health assessment is part of the COR-EMR program.

•

90% of the health assessments will be conducted by a physician, physician

assistant, nurse practitioner, or registered nurse under the supervision of a physician.

Review of health assessment data at the July Monitor visit showed that an RN or physician conducted 100% of the assessments.

•

90% of the health assessments must be completed within 14 days of arrival at the

facility.

PRJ data for July showed 92% of the assessments were completed in the required timeframe. This is consistent with information reviewed during the July Monitor site visit.

•

90% of medical problems identified during the initial assessment, will result in

the patient being referred to a Physician for follow-up care.

Review of records indicated that over 95% of the medical problems identified during the health assessment initiated a referral. While there was a delay in some referrals to the medical provider, once seen the medical problems were addressed.

SICK CALL

•

100% of the nursing protocols will be signed by the medical director.

The medical director has signed all the nursing protocols.

•

100% of the nursing protocols will address common symptoms, instruct nurses

about the questions of symptoms, identify objectives that they should accomplish in

evaluating prisoners who arrive with symptoms.

Nursing protocols are consistent with current guidelines and address common symptoms, are instructive to nurses concerning symptoms that may be encountered. The protocols identify quantitative objectives that should be accomplished as offenders are evaluated and treated.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

90% of sick call slips will be properly triaged identifying medical needs and

ensuring that inmates are referred for, and provided with, appropriate treatment within a

timely manner.

An identified area of concern was the process by which sick call slips are triaged. On the second visit the Monitor worked to assist the DON on a system to triage the sick call slips. On the third visit, while some triaging was occurring, it was not consistent and the Monitor discussed with the DON/HSA a process to prioritize the sick call slips. By the third day of the most recent visit a 5 point severity index was in place.

•

A Physician will provide overview of the sick call process through a monthly

review of the nurses performing sick call (in order to ensure that personnel are not

practicing beyond their training).

This item has not been addressed. This was also noted in the PRJ monthly aggregated report.

•

The monthly review will determine if the medical personnel are providing

appropriate care and whether they are following facility policy and procedure.

There were no instances noted by COR-EMR review where Medical personnel had provided inappropriate care. There were no instances noted where medical personnel were not following policy and procedure. But there was no indication that the physician had also conducted a review of sick calls.

The grievance process is noted in the monthly report. The grievance process is one way to check on the quality of care for offenders. Review of the grievances during the July Monitor visit identified that the resolution suggested by PRJ/MEDIKO was not evident on the documentation. The follow up to the concern also was not noted in either the grievance documentation or on the patient COR-EMR document. Grievance documents are not part of the medical record, but a review of the medical record after a grievance was written did not show specific resolutions to the concerns raised by the offender. This was only based on a couple of grievances.

CORRECTIONAL STAFF TRAINING

•

100% of correctional officers are trained in providing first responder medical

care and are basic cardiac life support (BCLS) certified.

On the first and second visit all correctional personnel had been recently trained. The July reports documented most of the correctional staff was current on infectious disease and emergency procedures required training.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

Curriculum is submitted for trainings to Monitor and DOJ for review and

approval prior to first training offered.

Training curriculum has been provided to the Monitor and DOJ for review and was approved.

•

100% of new hires will be provided an introductory training, as well as annual

in-services trainings provided to all staff.

All new hires have received their required training. As noted above some of the renewals are behind.

•

100% of the Suicide Prevention & Mental Health Care training is conducted by a

Qualified Mental Health Professional.

On the first and second visit it was noted that the Qualified Mental Health Professional (QMHP) had provided the suicide prevention training. On the third visit, the new QMHP, Kimberly Harris was unaware of the requirement. While unaware, she indicated a willingness and desire to provide training to officers and other medical staff as needed. Information submitted in the July report indicated that the majority of the correctional staff had attended suicide prevention training in July and early August 2014.

•

Curriculum is submitted to the monitor and DOJ for review and approval prior to

first training.

The curriculum was submitted to the Monitor and the DOJ for review and was approved.

CO-PAYS

•

100% of health care required by the Jail, including health assessments and

mental health care, as well as necessary medical care, including chronic care and

emergency visits are excluded from a co-pay charge to the inmate.

According to PRJ policy health assessment, mental health care, chronic care, necessary medical care and emergency visits are excluded from co-pay charges.

• 100% of the inmates will only have one co-payment fee to see a nurse for sick call, with no further fee assessed if the prisoner is referred to the doctor for further evaluation.
According to PRJ policy co-pay charges are not assessed to any offender.
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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

100% of the inmates will have no co-payment for serious medical need that is

clinically indicated, nor charging of multiple co-payments if more than one time care

occurs during any 30-day period for the same serious medical need.

According to PRJ policy co-pay charges are not assessed to any offender.

•

The PRJ will follow pre-determined agreement of co-payment scheduled as

outlined in DOJ Settlement Agreement, no co-payment will be charged if the co-payment

would cause the balance in a prisoner’s account to go below $5.00.

Co-payment schedule:

$2.00 to see a nurse: $3.00 to see a Doctor; and $8.00 for an emergency visit (i.e. visit on an expedited basis) if it is determined that an expedited visit was medically unnecessary.

According to PRJ policy co-pay charges are not assessed to any offender.

MENTAL HEALTH

•

The facility will provide (1) Full-time QMHP and (1) Psychiatrist who is onsite at

the Jail no less than once per week for a number of sufficient provider hours.

Kimberly Harris is the new QMHP. She is on-site Monday – Friday and on-call at other times. The Psychiatrist is available once per week to see offenders. This meets the requirement.

•

The facility will provide Telemedicine and additional in-person assessments

provided by the Psychiatrist where clinically indicated.

Telemedicine/telepsychiatry is not currently provided as the PRJ is able to provide Psychiatrist services on site.

•

Piedmont will perform a staffing analysis October 1, 2014 and each year

afterwards. The analysis will be submitted to and approved by Monitor and DOJ. The

analysis must demonstrate that staffing ratios are appropriate to meet the need and if the

analysis shows a deficiency the facility must increase the staffing to ensure constitutional

mental health care.

The analysis should occur over the next month. The analysis will be reviewed at the next on-site Monitor visit.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

MENTAL HEALTH POLICIES

•

100% of the policies are implemented based on NCCHC Jail Standards related to

MH Care.

Policies reviewed were consistent with NCCHC Jail standards.

•

100% of the prisoners are appropriately screened for mental illness using

appropriately validated screening instrument.

The screening instrument that is used is a part of the initial receiving screening of offenders, and has been validated. Screening occurred from 0-72 hours. Due to that fact, the potential for an adverse event is present. None have occurred during this first review period.

•

100% of prisoners with known or suspected mental illness are referred to a

psychiatrist within 14 days of intake. Acute needs are seen and treated as soon as staff is

made aware of the condition.

According to the July PRJ monthly report and Monitor review, referrals are taking an average of 17 days. Due to this fact there needs to be a strong effort to identify and assure that those with mental health issues are seen within the required period.

•

100% of prisoners with chronic mental illness are placed on a chronic mental

health list for follow-up every 30, 60, or 90 days or, as clinically indicated.

From the first monitor visit to the third visit there had been a staff change. The new QMHP had been on site less than a month. Therefore data was not available to corroborate this item. The new QMHP had not been given a copy of any of the documentation related to the settlement agreement. She was provided same during the July visit.

•

100% of psychotropic medication prescriptions will be reviewed by a psychiatrist

on a regular, timely basis to assess prescribed regimen.

During the July monitor site visit, the Monitor and the QMHP reviewed mental health medications lists. She was able to identify those offenders who were on the mental health roster and those on specific medications. She then made a list for the psychiatrist who would review the medication list with the patient on the next visit. An item that was noted, and was known by medical staff, was difficulty re-ordering medications from the

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
local pharmacy. This was being worked on while on-site during the July visit. Corrections to this process will be reviewed at the next on-site visit.

•

100% of the patients who have had a discontinued, added or changed

psychotropic medication will have a Psychiatrist or other qualified prescriber document

the reason for change in the COR-EMR health record.

Medications were noted in the COR-EMR as were specific notations by the QMHP and psychiatrist regarding medication delivery and compliance. As the QMHP was new this requirement was not addressed at the July visit and will be evaluated at the next Monitor visit.

•

100% of prisoners receiving psychotropic meds are adequately monitored for

negative side effects.

At the July visit the new QMHP had a list of potential issues to be discussed with the psychiatrist when he visited the facility. There were no notations in the COR-EMR recording negative side effects of a psychiatric mediation.

•

100% of prisoners on psychotropic medications will be evaluated by the

psychiatrist within two weeks of starting any new medication.

The new QMHP was unaware of this standard and stated she would assure that this was taken into account when scheduling offenders. This standard will be reviewed at the next site visit.

SUICIDE PREVENTION

•

A suicide prevention policy will be implemented to ensure that prisoners at risk of

self harm are identified, protected, and treated in a manner consistent with Constitution

law.

A suicide prevention policy was developed and has been approved by the Monitor and the DOJ. The policy adheres to the NCCHC standard. A challenge for the facility is the physical plant. The cells being used for suicide watch are in the booking and receiving area and not set up for suicide watch. There are protrusions in the cells used for suicide watch that pose a risk and as such the potential for a successful suicide exists. The PRJ is making an effort to modify the cells and have plans to continue to modify them as necessary.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

100% of those prisoners at risk for self-injurious behavior or suicide have timely

and adequate access to QMHP.

Review of the notes from the QMHP and direct observation by the Monitor has noted that those offenders under suicide watch have access to and regular visits from the QMHP.

•

100% of those prisoners on suicide watch are provided with the appropriate level

of supervision.

The current location of the suicide watch cells is located in the booking and receiving area. This location is staffed 24 hours a day and those that are on watch are able to have supervision by the officers who staff that location.

•

100% of actively suicidal prisoners are placed on constant observation.

During the visits to the facility by the Monitor there were no offenders on the highest level of watch. Therefore the Monitor was not able to observe if this measure was followed. Policy dictates that constant observation is required for those on the highest level of suicide watch. It was noted in the PRJ monthly reports that there had been offenders on the highest level of watch.

•

100% of potentially suicidal prisoners are monitored at staggered intervals not to

exceed every 15 minutes.

Review of documentation during each of the three visits showed that the officer responsible for the suicide watch signed the documentation at exactly 15 minute intervals. The standard is “staggered intervals”. This issue was discussed with the compliance director and is to be addressed with the officers responsible for suicide watch. The reasoning behind the staggered intervals is to make it more difficult for the offender under watch to time when the officer would be observing the offender.

•

100% of the Correctional Officers checks on prisoners on observation are

documented in the approved format.

As noted above, documentation was present, but the intervals were exactly 15 minutes, therefore it was difficult to ascertain if the officer actually was observing the offender at the 15 minute time frame or merely documenting that it was completed. When the Monitor was observing the officers they did go to the cell and observe the offender every 15 minutes on the dot.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

•

CO Supervisor will conduct and document a review of all documents at the end of

shift it occurred to ensure compliance.

Notes were reviewed at the three visits and the CO supervisor had reviewed all the suicide observation logs.

•

All staff with contact with prisoners have ready access to cut-down tools and are

trained to use them effectively.

At the first visit cut-down tools were not readily available. Over the course of the three visits cut-down tools were available to supervisory staff. The compliance director is working with security to make the cut-down tools more readily accessible in all housing areas. This is a challenge to security to assure that there is access to the tool for staff, but not for offenders.

•

QMHP (or Physician in absence of QMHP) regularly document in prisoners

medical chart, once per shift minimum, reassessing whether the level of precaution

should be raised or lowered for prisoners on suicide precautions based on that

assessment.

Review of documentation during the last visit showed that Kimberly Harris, the most recent QMHP, was documenting on the COR-EMR system the current status and recommendations to the psychiatrist for those on suicide watch and those that were in restricted housing areas.

QUALITY ASSURANCE

•

The facility has quality assurance policies and procedures that will identify and

address serious deficiencies in medical and mental health care (including sick call,

health assessments, intake, chronic care, medication administration, emergency care,

and infection control).

The quality assurance process is in its infancy. PRJ began sending Monthly reports in April and at the same time identified severe problems between the custody computer system and COR-EMR. These were significantly addressed just prior to the July Monitor site visit. Therefore it has been difficult for the PRJ to provide a comprehensive assessment of the quality of their system. The policy is in place, and the new DON/HSA Mary Trammel-Jones and compliance director Jim Davis are working together to address this item.

•

Track and analyze patterns and trends regarding the provision of medical and

MH care at Piedmont facility. (See Checklist)

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
As noted above, the monthly reports began in April of 2014. During the first few reports the Monitor and the compliance director worked on addressing any confusion on the way in which data for the reports are collected and presented in the report. At the July site visit the Monitor and compliance director sat down and reviewed each in the aggregated report to assure that each of the parties understood how the information was gathered and what each of the data points was addressing.
The report is currently a data report with little analysis of what happened and what steps my have been taken, or should be taken in the future to modify policies/procedures/systems at PRJ. An example could be the offender who had urinary retention and hematuria. He was sent to the ER four times in ten days. This may have been appropriate and necessary, but an analysis of the situation may help to understand and develop procedures to better care for offenders with catheters. Another example would be the use of the restraint chair. Why was it needed? What were the circumstances? What was the medical follow-up of the offender?
In the July report it was noted that a cell designated for medical usage was created. What are the new policies that are required for the new cell? What is the oversight by medical for that patient? IS there specific documentation that goes along with the camera in the room? Are vital signs taken on a routine basis? These are the types of quality assurance questions that should be answered as we work on this area of the agreement. Over the next few months this Monitor is hopeful that the data and analysis will continue to show improvement.

Compliance Indicators

Subject

Indicator

MEDICAL

Staffing

Staffing - Physician

3.5 hours of physician time per week for every 100 prisoners

Staffing Based on Offender Count

Count Below 600: Minimum of (1) RN and (6) LPNs (count below 600) / Count Above 600: Additional (2) LPNs

Staffing - Health Assessment Hire Additional (1) RN if Health Assessments are not being

Backlog

completed within 14 days

Medical Staff Requirements

All persons providing care meet applicable state licensure and/or certification requirements and practice within scope of training/licensure.

CNAs

Only performing tasks within support functions (e.g. vitals,

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

prepping charts, etc.)

Correctional Officers
Policies Policies & Procedures NCCHC Standards - Policies
Intake Medical Screening Initial Screenings Referrals
Chronic Care Chronic Care Program Guidelines
Health Assessments System Development & Implementation Assessment
Timing Referrals

Clear guidelines in place for any individuals providing clinical support, with physician oversight. CO's should not provide any type of non-emergency medical care.
Shall be revised to establish clear direction and expectations for all staff
All policies should be revised consistent with the 2008 National Commission on Correctional Health Care Jail Standards. (38 standards for policies - see check list)
Medical Screening portion of Intake Screening is performed by a Qualified Health Professional
Initial Screenings are fully documented and available to medical staff in each offenders’ medical file.
Policies adopted consistent with applicable professional standards providing guidance when prisoners should be referred to a physician after initial intake screening.
Implement policy with disease-specific clinical guidelines.
Guidelines must do the following: (1) defines illnesses that qualify for inclusion in the program (2) ensures that prisoners with chronic care issues are identified and examined by the physician/tracks prisoners in the program (3) schedules periodic assessments (4) provides for diagnostic tests at an initial comprehensive visit (5) makes lab work available at appointments in order to determine the status of disease control (6) outlines a clinical plan for each chronically ill prisoner.
Develop and implement a system to provide each prisoner with a comprehensive health assessment.
Conducted by a physician, physician assistant, nurse practitioner, or registered nurse under the supervision of a physician.
Health Assessment must be complete within 14 days of arrival
Referred to Physician for follow-up care (If medical problems are identified)

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

Sick Call

Nursing Protocols

Established and signed by medical director. Should address common systems, instruct nurses about the questions of symptoms, identify objectives that should accomplish in evaluating those prisoners

Triage

Properly triaged prisoners medical needs and ensure that they are referred for, and provided with, appropriate treatment win a timely manner.

Physician Oversight

Physician provides overview of sick call process through monthly review of the nurses performing sick call (in order to ensure that personnel are not practicing beyond their training)

Physician Oversight

Personnel are providing appropriate care during sick call and following facility policy and procedures

Correctional Staff Training

Annual Officer Training (AOT)

Providing first-responder medical care and basic cardiac life support (BCLS) certified.

AOT Curriculum

Curriculum submitted for AOT trainings to Monitor and DOJ for review and approval prior to first training offered.

Suicide Prevention & Mental Including an introductory training provided to new hires as

Health Care

well as annual in-services trainings provided to staff.

Curriculum & Training

Suicide Prevention & Mental Health Care training should be conducted by Qualified Mental Health Professionals and curriculum submitted to the monitor and DOJ for review and approval prior to first training.

Co-Pays

Excluded Co-Payments

All health care required by the Jail, including health assessments and mental health care, as well as necessary medical care, including chronic care and emergency visits

Required Co-Payments

Only one co-payment fee to see a nurse, with no further fee assessed if the prisoner is referred to the doctor for further evaluation.

Follow-up Care

No co-payment is required for serious medical need that is clinically indicated, nor charging of multiple co-payments if more than one time care occurs during any 30-day period for the same serious medical need.

Co-payment Schedule

Follows pre-determined agreement of co-payment scheduled as outlined in DOJ Settlement Agreement.

MENTAL HEALTH (MH)

Staffing

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

Qualified Mental Health

(1) Full-time QMHP and (1) Psychiatrist who is onsite at

Professionals (within 180 days the Jail no less than once per week for a number of

of effective date)

sufficient provider hours

Psychiatrist

Telemedicine and additional in-person assessments provided

MH Staffing Analysis (to begin one year after effective date)

Submitted to and approved by Monitor and DOJ. Must demonstrate staffing ratios increased to provide adequate MH care.

Policies

NCCHC Jail Standards

Implemented policies based on NCCHC Jail Standards related to MH Care.

MH Illness

All Prisoners are appropriately screened for mental illness using appropriately validated screening instrument.

Referrals

All prisoners with known or suspected mental illness are referred to psychiatrist within 14 days of intake. Acute needs are seen and treated as soon as staff are made aware of condition.

Chronic Mental Illness

Prisoners with chronic mental illness are placed on a chronic mental health list for follow-up every 30, 60, 90 days or as clinically indicated.

Psychotropic Medications

Psychiatrists must review prescriptions for psychotropic medications on a regular, timely basis to assess prescribed regimen.

Change of Psychotropic Medication

Discontinued, added or changed psychotropic medication, Psychiatrist or other qualified prescriber must document the reason for change in the prisoners health record.

Psychotropic Medication Monitoring

Prisoners receiving psychotropic meds are adequately monitored for negative side effects.

Psychotropic Medication Reevaluations

Prisoners on psychotropic medications must be evaluated by the psychiatrist within two weeks of starting any new medication.

Suicide Prevention

Suicide Risk

Those prisoners at risk for self-injurious behavior or suicide have timely and adequate access to QMHP

Suicide Watch

Those prisoners on suicide watch are provided with the appropriate level of supervision.

Actively Suicidal Prisoners

Actively suicidal prisoners are placed on constant observation

Potentially Suicidal Prisoners Monitored at staggered intervals not to exceed every 15 minutes.

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN

Documented Checks

Correctional Officers checks on prisoners on observation document checks in approved format.

CO Change of Shift

CO Supervisor will conduct and document a review of all documents at the end of shift it occurred to ensure compliance.

Training Tools

All staff with contact with prisoners have ready access to cut-down tools and are trained to use them effectively.

QMHP Re-Assessments

QMHP (or Physician in absence of QMHP) regularly document in prisoners medical chart, once per shift minimum, reassess level for prisoners on suicide precautions.

Quality Assurance

Quality Assurance Policies and Procedures (within 180 days of the Effective Date)

Identify and address serious deficiencies in medical and mental health care (including sick call, health assessments, intake, chronic care, medication administration, emergency care, and infection control)

Monthly Quality Assurance Track and analyze patterns and trends regarding the

Mechanisms (within 180 days provision of medical and MH care at Piedmont facility.

of the Effective Date)

(See Checklist)

Legend: SC PC NC NP

Substantial Compliance Partial Compliance Non Compliant No Program Indicator Removed Not Applicable for Site at this time

Standards Checklist Access to Care Responsible Health Authority Medical Autonomy Administrative Meetings and Reports Policies and Procedures

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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
Continuous Quality Improvement Program Emergency Response Plan Communication on Patients' Health Needs Infection Control Program Credentialing Professional Development Health Training for Correctional Officers Medication Administration Training Inmate Workers Pharmaceutical Operations Medication Services Information on Health Services Receiving Screening Transfer Screening Initial Health Assessment Mental Health Screening and Evaluation Oral Care Nonemergency Health Care Requests and Services Emergency Services Segregated Inmates Continuity of Care During Incarceration Chronic Disease Services Patients with Special Health Needs Infirmary Care (Currently inapplicable, but to be adopted should Piedmonth contruct an infirmary) Basic Mental Health Services Suicide Prevention Program Intoxication and Withdrawal Care of the Pregnant Inmate Health Record Format and Contents
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Piedmont Regional Jail • First Monitor Report • Prepared By James C. Welch, RN
Confidentiality of Health Records Restraint and Seclusion (Currently inapplicable, but to be adopted should Piedmont begin using restraints Emergency Psychotropic Medication
22


 
 Piedmont Regional Jail Authority Second Monitor Report
April 3, 2015
James Welch, RN, HNB-BC

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN
April 3, 2015
The report is based on the Qualitative and Quantitative measures as required by the settlement agreement with the Piedmont Regional Jail (PRJ). Each measure will be evaluated against the reports as presented to the Monitor and site visits conducted. Reports such as the monthly report from PRJ have been used to provide this document. This second report will use the same format as was used in the first report. There are also specific indicators identified in the settlement agreement. This report will highlight where PRJ has moved toward substantial compliance. The indicator spreadsheet is an attachment to this initial report. This report will provide a grading using the indicators. Some of the indicators will be in partial compliance as some of the processes and policies have just recently been developed and implemented.
Site visits were conducted on January 19 – 21, 2015 and March 16- 18, 2015. Monthly reports from PRJ were reviewed and data verified during site visits. Site medical staff and correctional staff were interviewed to assess the validity of the data and observations. The staff at the PRJ have been cooperative and helpful for the work of this Monitor. No areas of the facility have been off limits, nor have there been any restrictions placed on the movement of the Monitor to visit any areas within the facility.
Don Hunter, Superintendent of the Piedmont Regional Jail, and his staff are fully engaged and willing to work with the Monitor to improve conditions at the Jail. During these visits Superintendent Hunter indicated that the PRJ is under negotiations with the State to help fund an expansion to the facility. These physical plant changes should help the PRJ to continue to improve the health and mental health services provided at the facility.
Jim Davis, the PRJ compliance director, has been extremely helpful in providing information and documents needed for the continuing review of the PRJ.
All the staff at the PRJ is committed towards making the system better. The improvements, conditions and policies at the jail have shown significant movement since the first Monitor report.
While there is not a specific item in the settlement agreement about the physical space provided, the PRJ has made significant improvements to the medical areas. The physical space is better laid out and the increase in the examination areas, and ability of the physician and dentist to examine patients has been much improved due to the increased space. As noted above, the potential addition to the facility should only improve the provision of services to the jail population.
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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN
PRJ has made efforts towards achieving compliance with the settlement agreement and are to be commended for their efforts. The movement toward substantial compliance in most areas is an indication of their commitment to change. The addition of qualified management staff by Mediko has allowed PRJ to move toward substantial compliance in numerous areas. While changing a system takes time, they have shown that they are committed and willing to make the changes necessary to meet the medical and mental health needs of their offenders.

Qualitative and Quantitative Outcome Measures

MEDICAL CARE

•

1- The facility will provide 3.5 hours of physician time per week for every 100

prisoner.

The Average Daily Population (ADP) at the PRJ has been between 577 and 589 during the current Monitoring period. There were a few days when the census escalated to 600 and above, but only for a couple of days. The previous Physician staffing was Monday 7:30AM – 3:30PM, Wednesday 7:30AM – 1:30 PM and Thursday 7:30AM – 3:30PM. This gave the PRJ 22 hours of physician time per week. This meets the requirement as set forth in the settlement agreement. It was noted that Dr. Rula, the physician on staff, who had been the constant in the Medical area since the Monitoring period began left at the end of January. Other physicians have been providing services at the facility since his departure. The hours required by the settlement agreement have been provided by these part time physician staff. It was noted however that due to a snow storm there was one month were the time was slightly less than the required amount. This is understandable and does not negate the ongoing provision of services at the facility. It will be important that as the new permanent physician comes on board efforts are taken to ensure that when they are on vacation, a substitute physician is present to assure that the offenders at the facility obtain the required number of physician hours.

This standard is in substantial compliance.

•

2- For a Count Below 600: There will be a Minimum of (1) RN and (6) LPNs

(count below 600) / For a Count Above 600: There will be an Additional (2) LPNs.

There has been very little turnover on the nursing staff during this 6 month period. As of the March visit there were 6 LPN’s and 3 RN’s. This is an increase of 1 RN and 1 LPN since the last report. One of the RN’s is a Health Services Administrator/Director of Nurses (HSA/DON). The current staffing pattern meets the intent of the agreement with the additional RN and LPN on staff. The DON/HSA, Mary Trammell-Jones was new as of the first report. She continues to provide oversight and direction for the staff at PRJ nursing staff. The former Regional HSA, Janet Dobson is no longer employed with MEDIKO. Lori Peters was the new Regional HSA and has improved the quality of the processes in support of the site HSA. This change has significantly improved the Quality

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Assurance and assessment activities at PRJ. This seasoned professional is a welcome sight for the ongoing improvements seen at PRJ.

This standard is in substantial compliance.

•

3 - If Health Assessments are not being completed within 14 days the facility will

hire an additional (1) RN.

Data from the latest report showed that there were no health assessments that were not completed in the 14-day time frame. MEDIKO has hired an additional RN position. This has helped to assure that all health assessments are completed within the required time frame. There continues to be a challenge between the security computer system and the COR-EMR medical record system not communicating. This caused great confusion as to who was and was not in that 14 day period. The HSA has put in place mechanisms to assure that none of those in need of a 14 day assessment are missed.

This standard is in substantial compliance.

•

4 - All persons providing care will meet applicable state licensure and/or

certification requirements and, they will practice within the scope of their

training/licensure. Licenses will be up-to-date with no lapses.

Review of license documents shows that each of the medical and mental health staff is appropriately licensed. Orders reviewed, and policies assessed indicated staff functioning within the scope of their respective licensure.

This standard is in substantial compliance.

•

5 - Certified Nursing Assistants will only perform tasks as related to support

functions (e.g. vitals, prepping charts, etc.).

There were no CNA’s performing tasks at the facility.

This standard is in substantial compliance.

•

6 - Clear guidelines/policies are in place for any individuals providing clinical

support, with physician oversight. CO's should not provide any type of non-emergency

medical care.

Policies were approved and are in place. During the previous visits it was noted that there was no documentation of direct physician oversight. This has been corrected and documentation of direct oversight of all clinical activities is available. Electronic signature by the physician was present on all intakes and assessments for all records reviewed. PRJ policies do not allow for CO’s to provide any direct medical care to offenders.

This standard is in substantial compliance.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

POLICIES

•

7 - Policies shall be in place that establish clear direction and expectations for all

staff.

Policies are in place and are being reviewed on a routine basis. During this reporting period 6 policies have been reviewed and modified to better address care at the PRJ. The Monitor and the DOJ have reviewed and approved all policies.

This standard is in substantial compliance.

•

8 - All policies should be revised consistent with the 2008 National Commission

on Correctional Health Care Jail Standards. (38 standards for policies - see check list)

All policies have been consistent with the 2008 National Commission on Correctional Health Care Jail Standards. In the first report there was a question that this Monitor raised concerning the intake time frame. This policy was changed to address the importance of screening “on arrival”. This is consistent with the NCCH Jail Standards. To quote the Standard – “ Receiving screening is performed in all inmates on arrival at the intake facility to ensure that emergent and urgent health needs are met.” This was changed during this reporting period.

This standard is in substantial compliance.

INTAKE

•

9 - 90% of the Medical Screening portion of Intake Screening is performed by a

Qualified Health Professional.

100% of the Medical Screenings are performed by a Qualified Health Professional. All of the screenings are reviewed by the HSA as part of their quality assurance process.

This standard is in substantial compliance.

•

10 - 85% of the Initial Screenings are fully documented and available to medical

staff in each offenders on line medical file.

Intake screenings are available in the COR-EMR electronic system. Each (100%) was fully documented. If the COR-EMR system is not available at the time of the screening a paper screening is completed and entered at a later time into the system when it becomes available. This standard does not address the timeliness of the screenings, however, PRJ MEDIKO staff have instituted an improvement plan to address the timeliness issue. 40% of the transfer screenings were not completed in the time frame established by the facility in December. Their goal is 80%. By the January time frame 8% of the transfer screenings were not completed in the time frame established by the facility. By the January time frame they had met their improvement goal. This is an example of the good work being done by the staff at the PRJ and the improvements that can be made when an improvement process is implemented. A challenge that continues to plague the

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Medical staff is the interface between the COR-EMR and the defender management system. Superintendent Hunter has noted this as a problem and a new offender management system is scheduled to be in place in the July timeframe. This should substantially help the problems currently being seen with the interface between the systems.

This standard is in substantial compliance.

•

11 - Policies adopted will be consistent with applicable professional standards,

providing guidance when prisoners should be referred to a physician after initial intake

screening.

Policies are consistent with NCCHC standards. Delays, which had been seen in previous time periods, have been eliminated. From a low of 64% of offenders referred to a physician and seen, to the current 80% of those identified at intake as needing a referral this has shown significant improvement.

This standard is in substantial compliance.

CHRONIC CARE

•

12 - The Chronic Care policy will be implemented with disease-specific clinical

guidelines.

A chronic care policy has been developed, and has recently been implemented. While the clients may be seen for chronic conditions, a systematic approach to those with chronic illnesses was recently adopted. During the first and second visits the Monitor worked with the RN staff to develop a process for delivery of a chronic care program. Between the second and third visits a significant shift in medical and mental health personnel occurred which seemed to delay the implementation of the chronic care program. In the July PRJ monthly report, chronic care clinics had been conducted for four chronic care conditions (Cardiovascular, Endocrine, Respiratory, and Immunity). By the two visits in January and March respectively every chronic care client had been seen and a treatment plan was in place. The PRJ is using the NCCHC Chronic Care guideline as the template for chronic care conditions. This is a significant improvement from the previous reporting period.

This standard is in substantial compliance.

•

13 - The guidelines will define illnesses that qualify for inclusion in the program.

The guidelines identify those conditions that are included in the chronic disease program. Those conditions are: Cardiovascular, Endocrine, Gastroenterology, Respiratory, Neurology and Immunity.

This standard is in substantial compliance.

•

14 - 90% of prisoners with chronic care issues are identified and examined by the

physician

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

100% of the offenders identified with chronic care issues have been examined by a physician and have a treatment plan in place. It is unknown if any offenders were not identified in the screening process.

This standard is in substantial compliance.

•

15 - 95% of the prisoners in the program are tracked in the COR-EMR system.

100% of the offenders in the program are tracked in the COR-EMR system

This standard is in substantial compliance.

•

16 - 85% of the prisoners in the program are scheduled for periodic assessments.

All of the offenders who were identified are scheduled for those assessments, however as it has not been a month since each of them were seen data was not available to assess if the prisoners were scheduled based on degree of control.

This standard is in partial compliance.

•

17 - 85% of the prisoners in the program are provided diagnostic tests at the

initial comprehensive visit.

100% of the offenders who were seen in the chronic care clinics have been ordered diagnostic testing. It will be important to follow this process over the next reporting period to assure that testing and review by the physician occurs on a timely basis.

This standard is in substantial compliance.

•

18 - 85% of the lab work will be available at appointments to determine the level

of disease control.

Data were not available as the program was recently initiated. As the program was recently implemented it was impossible to obtain sufficient data to determine a percentage of compliance.

This standard is in partial compliance.

•

19 - 90% of chronic care patient’s will have a comprehensive clinical plan.

100% of the offenders in the chronic care program had a comprehensive clinical plan using the NCCHC Chronic care form.

This standard is in substantial compliance.

HEALTH ASSESSMENTS 7

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

•

20 - Develop and implement a system to provide each prisoner with a

comprehensive health assessment.

PRJ has developed and implemented a system to provide a comprehensive health assessment for those offenders who are in their custody for the 14 day period. The health assessment is part of the COR-EMR program.

This standard is in substantial compliance.

•

21 - 90% of the health assessments will be conducted by a physician, physician

assistant, nurse practitioner, or registered nurse under the supervision of a physician.

Review of health assessment data at the March Monitor visit showed that an RN or physician conducted 100% of the assessments. Out of the 10 records reviewed, where the health assessments were completed by an RN, all 10 were reviewed by the physician.

This standard is in substantial compliance.

•

22 - 85% of the health assessments must be completed within 14 days of arrival at

the facility.

PRJ data during my March visit showed 100% of the assessments were completed in the required timeframe.

This standard is in substantial compliance.

•

23 - 90% of medical problems identified during the initial assessment, will result

in the patient being referred to a Physician for follow-up care.

Review of records indicated that over 95% of the medical problems identified during the health assessment initiated a referral.

This standard is in substantial compliance.

SICK CALL

•

24 - Nursing protocols will be signed by the medical director.

The medical director has signed all the nursing protocols.

This standard is in substantial compliance.

•

25 - Nursing protocols will address common symptoms, instruct nurses about the

questions of symptoms, identify objectives that they should accomplish in evaluating

prisoners who arrive with symptoms.

Nursing protocols are consistent with current guidelines and address common symptoms, are instructive to nurses concerning symptoms that may be encountered. The

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

protocols identify quantitative objectives that should be accomplished as offenders are evaluated and treated.

This standard is in substantial compliance.

•

26 - 85% of sick call slips will be properly triaged identifying medical needs and

ensuring that inmates are referred for, and provided with, appropriate treatment within a

timely manner.

The January data showed this area to be in 97% compliance. In the February data report, and during my visit, data showed 100% compliance with this standard. This is a significant improvement from the previous reporting period.

This standard is in substantial compliance.

•

27 - A Physician will provide overview of the sick call process through a monthly

review of the nurses performing sick call (in order to ensure that personnel are not

practicing beyond their training).

In January data showed that 90% of the sick call encounters had been reviewed by the physician. During my visit and in the latest reports 100% of the sick call encounters reviewed had been reviewed. None of the data showed ay personnel practicing beyond their training or licensure.

This standard is in substantial compliance.

•

28 - The monthly review will determine if the medical personnel are providing

appropriate care and whether they are following facility policy and procedure.

There were no instances noted by COR-EMR review where Medical personnel had provided inappropriate care. There were no instances noted where medical personnel were not following policy and procedure.

One of the ways PRJ are reviewing this item is moving towards the use of the SOAP format of nursing notes. SOAP is subjective, objective, assessment and plan. This is a good way to evaluate if the professional is following standard procedures, providing appropriate care and is using protocols correctly, within their scope of practice.

This standard is in substantial compliance.

CORRECTIONAL STAFF TRAINING

•

29 - 85% of correctional officers are trained in providing first responder medical

care and are basic cardiac life support (BCLS) certified.

100% of the correctional officers are trained in providing first responder medical care and are basic cardiac life support certified.

This standard is in substantial compliance.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

•

30 - The curriculum for First Responder Medical Care trainings is submitted to

Monitor and DOJ for review and approval prior to first training offered.

Training curriculum has been provided to the Monitor and DOJ for review and was approved.

This standard is in substantial compliance.

•

31 - 85% of new hires will be provided an introductory training, as well as annual

in-services trainings provided to all staff.

100% of new hires have received their required training.

This standard is in substantial compliance.

•

32 - 85% of the Suicide Prevention & Mental Health Care training is conducted

by a Qualified Mental Health Professional.

The Suicide Prevention and Mental Health Care Training was conducted the week before my March visit and was conducted by the regional Mediko QMHP.

This standard is in substantial compliance.

•

33 - The curriculum for Suicide Prevention and Mental Health care training is

submitted to the monitor and DOJ for review and approval prior to first training.

The curriculum was submitted to the Monitor and the DOJ for review and was approved. As the policies at PRJ are modified or changed it will be important for the QMHP to revise the curriculum to reflect any changes in the policies or procedures.

This standard is in substantial compliance.

CO-PAYS

•

34 - 85% of health care required by the Jail, including health assessments and

mental health care, as well as necessary medical care, including chronic care and

emergency visits are excluded from a co-pay charge to the inmate.

The PRJ recently instituted a change to their co-pay policy initiating some co-pay charges. According to PRJ policy health assessment, mental health care, chronic care, necessary medical care and emergency visits are excluded from co-pay charges. In reviewing co-pay charges none were for health assessment, mental health care or emergency visits. This process was recently changed and less than a months’ worth of data were available.

This standard is in partial compliance.

•

35 - 85% of the inmates will only have one co-payment fee to see a nurse for sick

call, with no further fee assessed if the prisoner is referred to the doctor for further

evaluation.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

There were nineteen (19) offenders who were charged a sick call co-pay charge. Out of the 19, ten (10) were referred to the physician for follow-up. None of the 10 were assessed an additional charge for the physician visit. As this process had started recently it was difficult to obtain a substantial number of records to review.

This standard is in partial compliance.

•

36 - 85% of the inmates will have no co-payment for serious medical need that is

clinically indicated, nor charging of multiple co-payments if more than one time care

occurs during any 30-day period for the same serious medical need.

According to PRJ policy co-pay charges are not assessed to any offender who has a serious medical need that is clinically indicated, nor charging for any similar illness within a 30-day period. As this process had started recently, it was difficult to obtain a substantial number of records to review.

This standard is in partial compliance.

•

37 - The PRJ will follow pre-determined agreement of co-payment scheduled as

outlined in DOJ Settlement Agreement, no co-payment will be charged if the co-payment

would cause the balance in a prisoner’s account to go below $5.00.

Co-payment schedule:

$2.00 to see a nurse: $3.00 to see a Doctor; and $8.00 for an emergency visit (i.e. visit on an expedited basis) if it is determined that an expedited visit was medically unnecessary.

There were no co-pay charges in the 19 records reviewed which placed an offenders account below $5.00. However, as this process had recently been implemented it was difficult to obtain a substantial number of records to review.

This standard is in partial compliance.

MENTAL HEALTH

•

38 - The facility will provide (1) Full-time QMHP and (1) Psychiatrist who is

onsite at the Jail no less than once per week for a number of sufficient provider hours.

At the March visit the QMHP, Kimberly Harris was no longer employed by MEDIKO. MEDIKO had begun to fill in the position with staff from other sites and begun the recruitment process for the new QMHP. She was on-site Monday – Friday and on-call at other times. They have an on-call schedule for PRJ use as needed on off hours. The new Psychiatrist is available once per week to see offenders. This meets the requirement. As PRJ had only two days before my visit had a change in personnel, this standard had been met. Therefore as long as they continue to find a licensed QMHP they should continue to meet this standard.

This standard is in substantial compliance.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

•

39 - The facility will provide Telemedicine and additional in-person assessments

provided by the Psychiatrist where clinically indicated.

Telemedicine/telepsychiatry is not currently provided as the PRJ is able to provide Psychiatrist services on site. PRJ and MEDIKO has asked to be able to provide back-up telepsychiatry for times when a psychiatrist is not available quickly. They will be providing reports on the usage of telepsychiatry services and on-site services over the next couple of months for us to monitor how mental health services are being provided.

This standard is in substantial compliance

•

40 - Piedmont will perform a staffing analysis October 1, 2014 and each year

afterwards. The analysis will be submitted to and approved by Monitor and DOJ. The

analysis must demonstrate that staffing ratios are appropriate to meet the need and if the

analysis shows a deficiency the facility must increase the staffing to ensure constitutional

mental health care.

MEDIKO provided the required staffing analysis. Suggestions for continued analysis have been made to the staff at PRJ and MEDIKO. They will be reviewing the analysis to target the actual needs of the offenders at the facility to see if the current staffing pattern is adequate for the needs of the facility.

This standard is in substantial compliance.

MENTAL HEALTH POLICIES

•

41 - Policies are implemented to deliver mental health services as provided for in

the NCCHC Jail Standards related to MH Care.

Policies reviewed were consistent with NCCHC Jail standards.

This standard is in substantial compliance.

•

42 - 85% of the prisoners are appropriately screened for mental illness using

appropriately validated screening instrument.

The screening instrument that is used is a part of the initial receiving screening of offenders, and has been validated. 100% of the offenders were screened using the validated instrument. There were no adverse events that have occurred during this review period.

This standard is in substantial compliance.

•

43 - 85% of prisoners with known or suspected mental illness are referred to a

psychiatrist within 14 days of intake. Acute needs are seen and treated as soon as staff is

made aware of the condition.

Due to the fact that the QMHP was not available it was extremely difficult for the HSA and the regional nursing director to obtain validated data. It seemed that all offenders who were known or suspected to have a mental illness were referred within the

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

appropriate time frame, but data was not readily available. Therefore a partial compliance score was obtained. It will be critical that the new QMHP make a strong effort to identify and assure that those with mental health issues are seen within the required period. And, that acute needs are seen and treated as soon as staff are made aware of the condition.

This standard is in partial compliance.

•

44 - 85% of prisoners with chronic mental illness are placed on a chronic mental

health list for follow-up every 30, 60, or 90 days or, as clinically indicated.

Review of the chronic mental health list confirmed that those offenders on the list had been seen within the required time frame. It will be important for the new QMHP to work with the new psychiatrist to establish time frames that are based on clinical need of each person on the MH roster to assure that they are followed according to the clinical need of the individual.

This standard is in substantial compliance.

•

45 - 85% of psychotropic medication prescriptions will be reviewed by a

psychiatrist on a regular, timely basis to assess prescribed regimen.

It was noted that the just recently departed QMHP had appropriate lists of MH clients who were seen on a regular basis and the prescriptions were reviewed by the psychiatrist on a timely basis.

This standard is in substantial compliance.

•

46 - 85% of the patients who have had a discontinued, added or changed

psychotropic medication will have a Psychiatrist or other qualified prescriber document

the reason for change in the COR-EMR health record.

Medications were noted in the COR-EMR as were specific notations by the QMHP and psychiatrist regarding medication delivery and compliance. What was missing was the reason for the change in medications when they occurred. The review revealed that there was no consistency identifying the reason for changes in medication.

This standard is in partial compliance.

•

47 - 85% of prisoners receiving psychotropic meds are adequately monitored for

negative side effects.

As noted above COR-EMR had notations on some of the offenders who receive psychiatric medications, but there was not consistency noting negative side effects.

This standard is in partial compliance.

•

48 - 85% of prisoners on psychotropic medications will be evaluated by the

psychiatrist within two weeks of starting any new medication.

Review of the records with the HSA and regional nursing director showed that for those offenders who were placed on new psychiatric medications the psychiatrist had evaluated and seen the offender in the appropriate time frame.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN This standard is in substantial compliance.

SUICIDE PREVENTION

•

49 - A suicide prevention policy will be implemented to ensure that prisoners at

risk of self harm are identified, protected, and treated in a manner consistent with

Constitution law.

A suicide prevention policy was developed and has been approved by the Monitor and the DOJ. The policy adheres to the NCCHC standard. The PRJ recently modified a cell to adhere to the policy. There had not been any offenders who had been housed in the modified cell as of the March visit.

This standard is in substantial compliance.

•

50 - 100% of those prisoners at risk for self-injurious behavior or suicide have

timely and adequate access to QMHP.

Review of the notes from the former QMHP and direct observation during the January visit by the Monitor has noted that those offenders under suicide watch have access to and regular visits from the QMHP. The revised schedule for those covering during this recruitment period indicated that this should still occur.

This standard is in substantial compliance.

•

51 - 100% of those prisoners on suicide watch are provided with the appropriate

level of supervision.

The current location of the suicide watch cells is located in the booking and receiving area. This location is staffed 24 hours a day and those that are on watch are able to have supervision by the officers who staff that location. The newly modified suicide watch cell is to be staffed with personnel on a 24 hour basis with a radio.

This standard is in substantial compliance.

•

52 - 100% of actively suicidal prisoners are placed on constant observation.

During the visits to the facility by the Monitor there were no offenders on the highest level of watch. Therefore the Monitor was not able to observe if this measure was followed. Policy dictates that constant observation is required for those on the highest level of suicide watch. It was noted in the PRJ monthly reports that there had been one (1) offender on the highest level of watch. Review of the “constant observation sheet” had notes every 15 minutes exactly. A concern was raised that they observer must make notes in a random basis to assure that the individual is under constant observation.

This standard is in partial compliance.

•

53 - 100% of potentially suicidal prisoners are monitored at staggered intervals

not to exceed every 15 minutes.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Review of documentation during each of the visits showed that the officer responsible for the suicide watch signed the documentation at exactly 15 minute intervals. The standard is “staggered intervals”. This issue was discussed with the compliance director and is to be addressed with the officers responsible for suicide watch. The reasoning behind the staggered intervals is to make it more difficult for the offender under watch to time when the officer would be observing the offender.

This standard is in partial compliance.

•

54 - 100% of the Correctional Officers checks on prisoners on observation are

documented in the approved format.

As noted above, documentation was present, but the intervals were exactly 15 minutes, therefore it was difficult to ascertain if the officer actually was observing the offender at the 15 minute time frame or merely documenting that it was completed. When the Monitor was observing the officers they did go to the cell and observe the offender every 15 minutes on the dot.

This standard is in partial compliance.

•

55 - CO Supervisor will conduct and document a review of all documents at the

end of shift it occurred to ensure compliance.

Notes were reviewed at the three visits and the CO supervisor had reviewed all the suicide observation logs. However, as the CO supervisor had either not noted or understood the intent of the “staggered intervals “ requirement it was unclear if the CO supervisor had actually read and comprehended the document.

This standard is in partial compliance.

•

56 - All staff with contact with prisoners have ready access to cut-down tools and

are trained to use them effectively.

In the first report it was noted that cut-down tools were not readily available. Over the course of subsequent visits cut-down tools were available to all staff.

This standard is in substantial compliance.

•

57 - QMHP (or Physician in absence of QMHP) regularly document in prisoners

medical chart, once per shift minimum, reassessing whether the level of precaution

should be raised or lowered for prisoners on suicide precautions based on that

assessment.

Review of documentation during the visits showed that the former QMHP, Kimberly Harris, was documenting on the COR-EMR system the current status of the offender. But it was not clear that any specific recommendations were provided to the psychiatrist for those on suicide watch and those that were in restricted housing.

This standard is in partial compliance.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

QUALITY ASSURANCE

•

58 - The facility has quality assurance policies and procedures that will identify

and address serious deficiencies in medical and mental health care (including sick call,

health assessments, intake, chronic care, medication administration, emergency care,

and infection control).

The quality assurance process is in its infancy. PRJ has begun the QA process and has Quality Assurance Improvement charts that are assisting the MEDIKO staff in evaluating their processes and procedures. As noted previously there continue to be problems between the custody computer system and COR-EMR. Therefore it has been difficult for the PRJ to provide a comprehensive assessment of the quality of their system. The policy is in place, and the new DON/HSA Mary Trammel-Jones, regional director of nursing and compliance director Jim Davis are working together to address this item.

This standard is in partial compliance.

•

59 - Track and analyze patterns and trends regarding the provision of medical

and MH care at Piedmont facility. (See Checklist)

As noted above, the monthly reports began in April of 2014. During the first few reports the Monitor and the compliance director worked on addressing any confusion on the way in which data for the reports are collected and presented in the report. During the latest visit in March, the Monitor, HSA, regional nursing director and compliance director sat down and reviewed each item in the aggregated report to assure that each of the parties understood how the information was gathered and what each of the data points was addressing.

The report is currently a data report with some analysis of what happened and what steps my have been taken, or should be taken in the future to modify policies/procedures/systems at PRJ. It will be critical for MEDIKO and PRJ senior staff to meet and discuss the overall quality assurance process to assure that both security and MEDIKO management and line staff understand the importance of the process of quality assurance.

Over the next few months this Monitor is hopeful that the data and analysis will continue to show improvement.

This standard is in partial compliance.

16

Compliance Indicators
Subject MEDICAL
Staffing Staffing - Physician
Staffing Based on Offender Count
Staffing - Health Assessment Backlog Medical Staff Requirements
CNAs
Correctional Officers
Policies Policies & Procedures

Indicator
3.5 hours of physician time per week for every 100 prisoners Count Below 600: Minimum of (1) RN and (6) LPNs (count below 600) / Count Above 600: Additional (2) LPNs Hire Additional (1) RN if Health Assessments are not being completed within 14 days All persons providing care meet applicable state licensure and/or certification requirements and practice within scope of training/licensure. Only performing tasks within support functions (e.g. vitals, prepping charts, etc.) Clear guidelines in place for any individuals providing clinical support, with physician oversight. CO's should not provide any type of non-emergency medical care.
Shall be revised to establish clear direction and expectations for all staff

4/15
SC SC SC SC SC SC
SC

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

NCCHC Standards - Policies All policies should be revised consistent with the 2008

SC

National Commission on Correctional Health Care Jail

Standards. (38 standards for policies - see check list)

Intake

Medical Screening

Medical Screening portion of Intake Screening is performed

SC

by a Qualified Health Professional

Initial Screenings

Initial Screenings are fully documented and available to

SC

medical staff in each offenders’ medical file.

Referrals

Policies adopted consistent with applicable professional

SC

standards providing guidance when prisoners should be

referred to a physician after initial intake screening.

Chronic Care

Chronic Care Program

Implement policy with disease-specific clinical guidelines.

SC

Guidelines

Guidelines must do the following: (1) defines illnesses that

SC

qualify for inclusion in the program (2) ensures that

prisoners with chronic care issues are identified and

SC

examined by the physician/tracks prisoners in the program

(3) schedules periodic assessments (4) provides for

SC

diagnostic tests at an initial comprehensive visit (5) makes

lab work available at appointments in order to determine

PC

the status of disease control (6) outlines a clinical plan for each chronically ill prisoner.

SC

PC

SC

Health Assessments

System Development &

Develop and implement a system to provide each prisoner

SC

Implementation

with a comprehensive health assessment.

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Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Assessment

Conducted by a physician, physician assistant, nurse

SC

practitioner, or registered nurse under the supervision of a

physician.

Timing

Health Assessment must be complete within 14 days of

SC

arrival

Referrals

Referred to Physician for follow-up care (If medical

SC

problems are identified)

Sick Call

Nursing Protocols

Established and signed by medical director. Should address

SC

common systems, instruct nurses about the questions of

symptoms, identify objectives that should accomplish in

SC

evaluating those prisoners

Triage

Properly triaged prisoners medical needs and ensure that

SC

they are referred for, and provided with, appropriate

treatment win a timely manner.

Physician Oversight

Physician provides overview of sick call process through

SC

monthly review of the nurses performing sick call (in order

to ensure that personnel are not practicing beyond their

training)

Physician Oversight

Personnel are providing appropriate care during sick call

SC

and following facility policy and procedures

Correctional Staff Training

Annual Officer Training

Providing first-responder medical care and basic cardiac

SC

(AOT)

life support (BCLS) certified.

AOT Curriculum

Curriculum submitted for AOT trainings to Monitor and

SC

DOJ for review and approval prior to first training offered.

19

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Suicide Prevention & Mental Including an introductory training provided to new hires as

SC

Health Care

well as annual in-services trainings provided to staff.

Curriculum & Training

Suicide Prevention & Mental Health Care training should

SC

be conducted by Qualified Mental Health Professionals and

curriculum submitted to the monitor and DOJ for review

and approval prior to first training.

Co-Pays

Excluded Co-Payments

All health care required by the Jail, including health

PC

assessments and mental health care, as well as necessary

medical care, including chronic care and emergency visits

Required Co-Payments

Only one co-payment fee to see a nurse, with no further fee

PC

assessed if the prisoner is referred to the doctor for further

evaluation.

Follow-up Care

No co-payment is required for serious medical need that is

PC

clinically indicated, nor charging of multiple co-payments

if more than one time care occurs during any 30-day period

for the same serious medical need.

Co-payment Schedule

Follows pre-determined agreement of co-payment

PC

scheduled as outlined in DOJ Settlement Agreement.

MENTAL HEALTH (MH)

Staffing

Qualified Mental Health

(1) Full-time QMHP and (1) Psychiatrist who is onsite at

SC

Professionals (within 180 days the Jail no less than once per week for a number of

of effective date)

sufficient provider hours

Psychiatrist

Telemedicine and additional in-person assessments

SC

provided

20

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

MH Staffing Analysis (to

Submitted to and approved by Monitor and DOJ. Must

SC

begin one year after effective demonstrate staffing ratios increased to provide adequate

date)

MH care.

Policies

NCCHC Jail Standards

Implemented policies based on NCCHC Jail Standards

SC

related to MH Care.

MH Illness

All Prisoners are appropriately screened for mental illness

SC

using appropriately validated screening instrument.

Referrals

All prisoners with known or suspected mental illness are

PC

referred to psychiatrist within 14 days of intake. Acute

needs are seen and treated as soon as staff are made aware

of condition.

Chronic Mental Illness

Prisoners with chronic mental illness are placed on a

SC

chronic mental health list for follow-up every 30, 60, 90

days or as clinically indicated.

Psychotropic Medications

Psychiatrists must review prescriptions for psychotropic

SC

medications on a regular, timely basis to assess prescribed

regimen.

Change of Psychotropic

Discontinued, added or changed psychotropic medication,

PC

Medication

Psychiatrist or other qualified prescriber must document the

reason for change in the prisoners health record.

Psychotropic Medication

Prisoners receiving psychotropic meds are adequately

PC

Monitoring

monitored for negative side effects.

Psychotropic Medication Re- Prisoners on psychotropic medications must be evaluated

SC

evaluations

by the psychiatrist within two weeks of starting any new

medication.

21

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Suicide Prevention

Policy A

Suicide prevention policy will be implemented to ensure

SC

that prisoners at risk of self-harm are identified, protected,

and treated in a manner consistent with the Constitution

Suicide Risk

Those prisoners at risk for self-injurious behavior or suicide

SC

have timely and adequate access to QMHP

Suicide Watch

Those prisoners on suicide watch are provided with the

SC

appropriate level of supervision.

Actively Suicidal Prisoners Actively suicidal prisoners are placed on constant

PC

observation

Potentially Suicidal Prisoners Monitored at staggered intervals not to exceed every 15

PC

minutes.

Documented Checks

Correctional Officers checks on prisoners on observation

PC

document checks in approved format.

CO Change of Shift

CO Supervisor will conduct and document a review of all

PC

documents at the end of shift it occurred to ensure

compliance.

Training Tools

All staff with contact with prisoners have ready access to

SC

cut-down tools and are trained to use them effectively.

QMHP Re-Assessments

QMHP (or Physician in absence of QMHP) regularly

PC

document in prisoners medical chart, once per shift

minimum, reassess level for prisoners on suicide

precautions.

22

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN

Quality Assurance

Quality Assurance Policies

Identify and address serious deficiencies in medical and

PC

and Procedures (within 180 mental health care (including sick call, health assessments,

days of the Effective Date)

intake, chronic care, medication administration, emergency

care, and infection control)

Monthly Quality Assurance Track and analyze patterns and trends regarding the

PC

Mechanisms (within 180 days provision of medical and MH care at Piedmont facility.

of the Effective Date)

(See Checklist)

Legend:

SC

Substantial Compliance

43

PC

Partial Compliance

16

NC

Non Compliant

0

NP

No Program

0

Indicator Removed

Not Applicable for Site at this time

23

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN
Standards Checklist
Access to Care Responsible Health Authority Medical Autonomy Administrative Meetings and Reports Policies and Procedures Continuous Quality Improvement Program Emergency Response Plan Communication on Patients' Health Needs Infection Control Program Credentialing Professional Development Health Training for Correctional Officers Medication Administration Training Inmate Workers Pharmaceutical Operations Medication Services Information on Health Services Receiving Screening Transfer Screening Initial Health Assessment Mental Health Screening and Evaluation Oral Care
24

Piedmont Regional Jail • Second Monitor Report • Prepared By James C. Welch, RN
Nonemergency Health Care Requests and Services Emergency Services Segregated Inmates Continuity of Care During Incarceration Chronic Disease Services Patients with Special Health Needs Infirmary Care (Currently inapplicable, but to be adopted should Piedmonth construct an infirmary) Basic Mental Health Services Suicide Prevention Program Intoxication and Withdrawal Care of the Pregnant Inmate Health Record Format and Contents Confidentiality of Health Records Restraint and Seclusion (Currently inapplicable, but to be adopted should Piedmont begin using restraints and seclusion) Emergency Psychotropic Medication
25

 
 Case: 3:13-cv-00646-JRS As of: 03/18/2014 09:50 PM EDT 1 of 2
U.S. District Court Eastern District of Virginia − (Richmond) CIVIL DOCKET FOR CASE #: 3:13−cv−00646−JRS

CLOSED

UNITED STATES OF AMERICA v. Piedmont Regional Jail Authority Assigned to: District Judge James R. Spencer Cause: 42 USC 1997 CRIPA
Plaintiff

Date Filed: 09/20/2013 Date Terminated: 10/01/2013 Jury Demand: None Nature of Suit: 440 Civil Rights: Other Jurisdiction: U.S. Government Plaintiff

UNITED STATES OF AMERICA

represented by Robert P. McIntosh United States Attorney's Office 600 E Main St 18th Fl Richmond, VA 23219 (804) 819−5400 Email: Robert.McIntosh@usdoj.gov LEAD ATTORNEY ATTORNEY TO BE NOTICED

Aaron Saul Fleisher United States Department of Justice 950 Pennsylvania Avenue NW Washington, DC 20530 **NA** (202) 307−6457 Fax: (202) 514−4883 Email: aaron.fleisher@usdoj.gov PRO HAC VICE ATTORNEY TO BE NOTICED

Eric H. Holder , Jr. Office of the United States Attorney 555 4th Street, N.W. Room 11−852 Washington, DC 20001 **NA** (202) 514−7280 ATTORNEY TO BE NOTICED

Defendant Piedmont Regional Jail Authority

represented by Zachary Daniel Cohen Thompson McMullan PC 100 Shockoe Slip 3rd Fl Richmond, VA 23219−4140 (804) 698−6255 Fax: (804) 649−0654 Email: zcohen@t−mlaw.com LEAD ATTORNEY ATTORNEY TO BE NOTICED

Date Filed 09/20/2013
09/20/2013

# Docket Text
1 COMPLAINT against Piedmont Regional Jail Authority, filed by UNITED STATES OF AMERICA. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Civil Cover Sheet)(jtho, ) (Entered: 09/20/2013)
2 Motion to appear Pro Hac Vice by Aaron Saul Fleisher and Certification of Local Counsel by UNITED STATES OF AMERICA. (jtho, ) (Entered: 09/20/2013)

Case: 3:13-cv-00646-JRS As of: 03/18/2014 09:50 PM EDT 2 of 2

09/20/2013 09/24/2013 09/27/2013 10/01/2013
10/09/2013 01/30/2014 02/03/2014

3 Joint MOTION Entry of Settlement Agreement by UNITED STATES OF AMERICA. (Attachments: # 1 Proposed Order, # 2 Exhibit Settlement Agreement)(McIntosh, Robert) (Entered: 09/20/2013)
4 SO−ORDER granting 2 Motion for Aaron Saul Fleisher to appear Pro hac vice on behalf of United States of America. Signed by District Judge James R. Spencer on 9/24/13. (jtho, ) (Entered: 09/24/2013)
6 WAIVER OF SERVICE Returned Executed by UNITED STATES OF AMERICA. Piedmont Regional Jail Authority waiver sent on 9/23/2013, answer due 11/22/2013. (cmcc, ) (Entered: 10/07/2013)
5 ORDER regarding 3 the parties' Joint Motion to Enter a Settlement Agreement; upon good cause, the Court GRANTS the Joint Motion and APPROVES the settlement reached by the parties, Plaintiff United States of America and Defendant Piedmont Regional Jail Authority, as set forth in the Settlement Agreement. Signed by District Judge James R. Spencer on 10/1/2013. Copies to counsel. (cmcc, ) (Entered: 10/01/2013)
7 NOTICE of Appearance by Zachary Daniel Cohen on behalf of Piedmont Regional Jail Authority (Cohen, Zachary) (Entered: 10/09/2013)
8 Joint MOTION for Extension of Reporting Deadlines by Piedmont Regional Jail Authority, UNITED STATES OF AMERICA. (Attachments: # 1 Proposed Order)(McIntosh, Robert) (Entered: 01/30/2014)
9 ORDER granting 8 Motion for Extension of Time to File. The reporting deadlines contained in the Settlement Agreement [Dkt No. 3−2], which was approved by the Court by Order entered October 1, 2013 5 , are hereby extended for a period of sixty (60) days.Signed by District Judge James R. Spencer on 02/03/2014. (tjoh, ) (Entered: 02/03/2014)